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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700920
Report Date: 08/20/2021
Date Signed: 08/20/2021 12:04:14 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/08/2021 and conducted by Evaluator Kevin Gould
COMPLAINT CONTROL NUMBER: 27-AS-20210408153755
FACILITY NAME:BELLA VILLA ELDERLY CAREFACILITY NUMBER:
342700920
ADMINISTRATOR:TUIMAUALUGA, PENINAFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 6DATE:
08/20/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Julie NonuTIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Resident's are unsupervised.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kevin Gould made an unannounced inspection to Bella Villa Elderly Care Group Home on 8/20/21 at 10:00 to conclude the investigation of the above allegation and to deliver the findings. LPA met with S1 and together discussed the investigation details.

Based on LPAs observations during the investigation process, the allegations have been corroborated because there was no awake staff when LPA arrived at the facility. Staff #2, (see confidential name list LIC-811 dated 8/20/21) was asleep and admitted to LPA being asleep due to caring for the residents the night before. No other staff on duty at the time of inspection.

The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of Neglect/Lack of Supervision is substantiated but if any additional information is received this complaint can be amended and the finding can be changed. LPA also observed that 4 of 6 resident records were not complete including but limited to admission agreements, needs and services plans, and family contact information.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20210408153755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELLA VILLA ELDERLY CARE
FACILITY NUMBER: 342700920
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2021
Section Cited
CCR
87411(a)
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Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee will ensure that the facility is staffed with an awake staff member at all times to meet the residents needs. Licensee will Submit update LIC 500 personnel report to ensure facility is adequately staffed. LIC 500 must be accurate and meet all labor requirements. Staff will received training on staff with signatures on training provided.
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This Requirement was not met as evidenced by LPAs observations of no staff awake and providing supervision to 6 of 6 residents in care which poses an immediate health and safety and personal rights risk for residents in care.
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 requirements to provide care and supervision. Civil Penalty assessed.
Type A
08/23/2021
Section Cited
CCR
87506(a)
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Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by LPA Gould reviewed residents files and observed 4 of 6
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Licensee will update all resident files and ensure all required documents are filled out entirely, and ensure all documents are re-signed by residents and authorized representatives. to ensure accuracy of original agreements. All documents signed prior to 8/20/2021 need to be reviewed and updated and resigned. Civil Penalty assessed.
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residents had incomplete records and admission agreements including missing monthly rates.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20210408153755
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: BELLA VILLA ELDERLY CARE
FACILITY NUMBER: 342700920
VISIT DATE: 08/20/2021
NARRATIVE
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The following deficiencies are cited per California Code Regulation, TITLE 22. Immediate civil penalty issued.

Exit interview was conducted with the facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 3