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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700920
Report Date: 05/27/2022
Date Signed: 05/27/2022 01:35:07 PM


Document Has Been Signed on 05/27/2022 01:35 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: 6DATE:
05/27/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Penina TuimaualugaTIME COMPLETED:
02:00 PM
NARRATIVE
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On 5/27/22 at 9:00am Licensing Program Analyst (LPA) Kevin Gould conducted a Case Management Deficiencies inspection to address violations LPA observed wile conducting an unrelated complaint investigation. LPA met with Administrator, Penina Tuimaualuga To discuss the violations observed.

LPA arrived at the facility and was immediately greeted by S1. LPA reviewed list of associated staff members and LPA did not observe the staff member to be associated to the facility. LPA confirmed S1 has a criminal record clearance but was not associated to the facility until after LPA arrived today. LPA asked staff S2 for S1's file and was informed that staff started last week and they have no documentation on file at the facility of required personnel documents to be retained at the facility Including but not limited to: LIC 501, LIC 508, LIC 503 and no documentation of training.

LPA immediately requested resident files and observed multiple errors in documentation of medication administration. R1 was missing medication documentation for 5/25, 5/26 and 5/27. R2 was missing medication documentation for 5/26 and 5/27. R3 was missing medication documentation for 5/25, 5/26 and 5/27. R4 was missing medication documentation for 5/26.

While conducting file review LPA observed R1 had a fall and ER visit on 3/27/22 and treated for a head laceration. LPA asked if there was an incident report and staff stated no. LPA has not received any incident reports.

When LPA arrived at the home he observed many items including bedding and furniture in the back yard and partially blocking the exit ramp from the living room. LPA asked S1 why the items were out here and refused to answer. When S2 arrived she informed LPA that the facility has a bed bug infestation and had items removed to treat the rooms. LPA was informed the bed bugs were discovered on 5/25 and LPA had not been notified.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Kevin GouldTELEPHONE: (619) 672-5924
LICENSING EVALUATOR SIGNATURE:
DATE: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022
NARRATIVE
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When LPA went into the back yard, LPA observed wood from fence repair that had been in the same position since LPA conducted an annual inspection on 3/9/22 and had not been removed.

The following deficiencies are cited per California Code of Regulations, TITLE 22.

Exit interview was conducted and a copy of this report and appeal rights were 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: 05/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 05/27/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited

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Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as evidenced by LPAs review of
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Associated staff and criminal record clearance and observed staff Sandra Robinson was not associated to the faciltiy at the time of inspection which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
05/31/2022
Section Cited

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Training requirements for direct care staff: All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:(1) Twelve hours of dementia care training, six of which shall be completed before a staff member begins working independently
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with residents, and the remaining six hours of which shall be completed within the first four weeks of employment. All 12 hours shall be devoted to the care of persons with dementia. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction. This requirement was not met as evidenced by facility staff stating to LPA that the facility has no employee file or documentation of training for Sandra Robinson which poses an immediate health safety and personal rights risk for residents in care.
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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: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 05/27/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/31/2022
Section Cited

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Personal Accommodations and Services: All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement was not met as evidenced by LPA's observation of residents furniture and personal items were removed from the back bedroom due to bed bug infestation which partially blocked the exit ramp of the facility
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which poses an immediate health, safety and personal rights risk to residents in care.
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Type A
05/31/2022
Section Cited

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Incidental Medical and Dental Care: The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement was not met as evidenced by LPA's file review where LPA observed multiple errors in documentation of medication administration. R1 was
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missing medication documentation for 5/25, 5/26 and 5/27. R2 was missing medication documentation for 5/26 and 5/27. R3 was missing medication documentation for 5/25, 5/26 and 5/27. R4 was missing medication documentation for 5/26 which poses an immediate health, safety and personal rights risk for residents in care.
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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: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 05/27/2022 01:35 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/30/2022
Section Cited

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Reporting Requirements: Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met as evidenced by LPAs arrival at the facility and observed items in the back yard, LPA was informed the facility has a bed bug infestation and are treating the affected rooms. LPA asked if an incident report has been submitted and was informed no LPA also received no phone calls regarding bed bugs. Additionally, while conducting file review. LPA observed resident Kevin Eggen had a fall on 3/27/22 and required emergency treatment at hospital for a head wound and no report was submitted to LPA. which poses a potential health, safety and personal rights risk to residents in care.
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Type B
05/30/2022
Section Cited

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Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by, LPA observed the fence was
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 repaired 4 months ago and LPA observed there is still a pile of wood boards in the back yard against the fence that still needs to be removed. LPA issued a technical violation on 3/9/22 and the items have not been removed. Facility states they called county for pickup but neglected to bring out items for removal which poses a potential health, safety and personal rights risk to residents in care.
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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: 05/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/27/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5