<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:18:33 PM


Document Has Been Signed on 03/22/2023 04:18 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 CARE IIFACILITY NUMBER:
342700922
ADMINISTRATOR:TUIMAUALUGA, PENINAFACILITY TYPE:
740
ADDRESS:3612 EASTERN AVETELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 4DATE:
03/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH: Aliti Waquala TIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 03-22-2023 at 1:00 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Brandon Panariello conducted an unannounced facility visit to conduct a case management. LPAs met with Aliti Waquala and explained the purpose of today's visit.

The purpose of the visit today is in response to learned deficiencies during complaint investigation 27-AS-20230313140053. It was learned resident 1 was residing in a staff room, and their admission agreement reports lodging status as a single room. Resident 1 is now in a shared room. Moreover, Resident 1's roommate lodging agreement is for a single room. As a result, the facility is not adhering to Resident 1 and resident 2 admission agreement and or plan of operation. The monthly rate payment is due on the 5th of the month, and the resident room changes occurred after payments were received, as the changes occurred on March 10, 2023. A a refund shall be assessed and provide to residents.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


Exit interview conducted, and a copy of the 809 report and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
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 2


Document Has Been Signed on 03/22/2023 04:18 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 II
FACILITY NUMBER: 342700922

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/05/2023
Section Cited

1
2
3
4
5
6
7
Each facility shall have and maintain a current, written definitive plan of operation...Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:...A copy of the Admission Agreement, containing basic and optional services. This requirement was not met as evidence by: Based on observation
1
2
3
4
5
6
7
The administrator agrees to update R1 and R2 admission agreements, which will reflect new monthly rate and shared room status by POC date 04/05/23 by 5 PM. The Administrator will email LPA Martinez copies of the admission agreement by POC date 04/05/23 5 pm
8
9
10
11
12
13
14
and file review, the Licensee did not ensure to change admission agreement or follow Admission agreement policy and update residents admission agreements when changes occur. R1 & R2 admission agreement lodging status is single and R1 R2 now share a room. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 03/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2