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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 12/13/2021
Date Signed: 03/07/2022 12:21:18 PM


Document Has Been Signed on 03/07/2022 12:21 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CAREFACILITY NUMBER:
342700920
ADMINISTRATOR:TUIMAUALUGA, PENINAFACILITY TYPE:
740
ADDRESS:37 MOSSGLEN CIRTELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95826
CAPACITY:6CENSUS: 5DATE:
12/13/2021
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Licensees Penina Tuimaualuga and Mark LabellaTIME COMPLETED:
12:00 PM
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An Informal Conference was conducted today, 12/13/2021, via Microsoft Teams. The purpose of the Informal Conference was to discuss the facilities compliance with Title 22 Regulations as a result of deficiencies cited during inspections on 4/13/21, 8/20/21 and 10/14/21. Present at today's Informal Conference were: Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analyst (LPA) Kevin Gould and Licensees, Penina Tuimaualuga and Mark Labella. The informal conference process was explained during this meeting.


The following issues were discussed during the informal conference:
  • Criminal record clearance for staff
  • Medication administration record errors
  • Resident records, missing or no records available
  • Staff Supervision
  • Staff records, no staff records available at time of inspection.


Licensees stated they will do the following to achieve continued and substantial compliance:
  • Submit new LIC 500 personnel report with updated staff schedules.
  • Licensees will contact assigned LPA or On Duty LPA to verify new staff have criminal record clearance before working at the facility.
  • Licensees have agreed to participate in Department's Technical support Program
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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