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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 02/16/2024
Date Signed: 02/16/2024 02:38:13 PM


Document Has Been Signed on 02/16/2024 02:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
02/16/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Yelena BigelowTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Jamie Ivey Canady arrived at the facility unannounced to conduct a fire clearance visit. LPA met with facility administrator Yelena Bigelow and explained the purpose of today' visit.

LPA met with Flor Olivares Fire Inspector regarding current facility issues. Areas of concern being addressed today are the following:

1. Self locking door knobs in room 6, front door and room 2. IS FIRE DEPT REQUIRING THE FACILITY TO HAVE THESE SELF LOCKING KNOBS - Fire Inspector Olivares stated "All exterior doors can have locking hardware if they want. Resident rooms do not have to have access back into the facility once outside. The fire code does not restrict the resident room from having unlocked or locked hardware. Bedrooms and bathrooms must have self releasing hardware. It is important to keep the facility as a home".

2. Room 6 Wheelchair Ramp. (ask about weight capacity and how much weight can this ramp hold) - Community Risk Reduction Division Fire Inspectors no longer covers ramps.

3. Back patio tiles, tripping hazard. ( will this hazard interfere with fire emergencies and removal of residents during a fire/other emergency?) - Tiles in the backyard are cleared.

4. Room 2 and 6 are there fire exit doors? If so what is an appropriate plan to keep exit door pathways clear. What does fire require. - Room 2 and 6 have cleared fire exit doors. Fire requires 36 inch width for all pathways. LPA and Fire Inspector Olivares observed facility staff administrator clear all pathways throughout the facility by removing and repositioning the bed in room 1.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was given to facility administrator Yelena Bigelow.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 02/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/16/2024
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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