342700922-3-22-2023-27-AS-KHOS-CQKJDS-20230404065801

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700922
Report Date: 03/22/2023
Date Signed: 03/22/2023 04:19:40 PM

Substantiated

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
03/13/2023 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230313140053

FACILITY NAME:	BELLA VILLA ELDERLY CARE II		FACILITY NUMBER:	342700922
ADMINISTRATOR:	TUIMAUALUGA, PENINA		FACILITY TYPE:	740
ADDRESS:	3612 EASTERN AVE		TELEPHONE:	(424) 345-0820
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY:	6	CENSUS: 4	DATE:	03/22/2023
		UNANNOUNCED	TIME BEGAN:	01:22 PM
MET WITH:	Aliti Waquala		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Facility is not adhering to their approved fire clearance.

INVESTIGATION FINDINGS:

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On 03-22-2023 at 1:00 PM, Licensing Program Analysts (LPAs) Avelina Martinez and Brandon Panariello conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA Martinez met with Aliti Waquala and explained the purpose of today's visit.

During today's visits, LPAs conducted interviews and inspected the facility. It was learned that resident 1 (R1) was residing in room 6, which is a staff room. In addition, resident 2 (R2) was residing in room 5, which is not fire cleared as a resident room. Resident 3 (R3) was residing in room 4, which is not a fire cleared resident room. Additionally, room 1 is designated as a single room, however, there are two residents residing in the room. Facility staff will be moving residents in room 1 to room 3 to adhere to the facility sketch. As a result, the facility is not adhering to their approved fire clearance.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20230313140053

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 II	FACILITY NUMBER: 342700922
	VISIT DATE: 03/22/2023

NARRATIVE

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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.

An immediate $500.00 civil penalty shall be assessed on March 22, 2023; based on the allegation: "Facility is not adhering to their approved fire clearance." Violation of California Code of Regulations Section 87203 was assessed on 03/22/2023. Because the facility did not adhere to fire clearance and fire safety regulation.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 27-AS-20230313140053

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 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 A 03/23/2023 Section Cited CCR 87203	1 2 3 4 5 6 7	87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met as evidence by: Based on file review and interviews, the Licensee did not ensure	1 2 3 4 5 6 7	Facility staff has relocated from a staff room to resident room. Facility staff agrees to email LPA Martinez resident room fire clearance plan by POC Date 03/23/2023 by 5 PM.
	8 9 10 11 12 13 14	residents were residing in designated resident rooms and following approved fire clearance. This posed an immediate 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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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