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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700922
Report Date: 01/11/2024
Date Signed: 01/11/2024 11:01:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/15/2023 and conducted by Evaluator Jamie Ivey-Canady
COMPLAINT CONTROL NUMBER: 27-AS-20231115090119
FACILITY NAME:BELLA VILLA ELDERLY CARE IIFACILITY NUMBER:
342700922
ADMINISTRATOR:ALITI WAQALALAFACILITY TYPE:
740
ADDRESS:3612 EASTERN AVETELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
01/11/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Yelena BegelowTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Staff financially abused resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Jamie Ivey Canady and Avelina Martinez conducted an unannounced facility visit to deliver complaint findings. LPAs met with current facility administrator Yelena Begelow and explained the purpose of today's visit.


The Department has determined the following as it relates to the allegations: Staff finanically abused resident





Cont on 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
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-20231115090119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELLA VILLA ELDERLY CARE II
FACILITY NUMBER: 342700922
VISIT DATE: 01/11/2024
NARRATIVE
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On 11/16/2023, 12/21/2023 and 01/10/2024 Licensing Program Analyst (LPA) Jamie Ivey Canady investigated current facility allegations. According to facility resident files, witness banking documentation, facility staff interviews and facility resident interviews, it was learned that R1 was a victim of financial abuse by facility staff. A police report was filed with the Sacramento County Sheriffs' Department, and the police report number is 23-408334. According to R1 conservator banking receipts, R1 banking institution refunded all defrauded funds to R1 account. However, based on a preponderance of evidence the allegation Staff financially abused resident is Substantiated. Based on LPAs observations and interviews which were conducted  the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.  California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Exit interview with Administrator. Appeal rights and report given.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 27-AS-20231115090119
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLA VILLA ELDERLY CARE II
FACILITY NUMBER: 342700922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/11/2024
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities(a) In addition to the rights listed...(8)To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse...This was not met as evidenced by:
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Licensee stated facility will disassociate S2 from all facilities No Later Than 1/12/2024. Staff training regarding not having access to resident's financial information will be emailed to LPA NLT 1/12/2024.
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Licensee did not ensure facility staff did not finanically abuse facility resident in accordance with Title 22 Regulations. This poses an immediate Health and Safety risk to person's 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) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3