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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 02/15/2024
Date Signed: 02/15/2024 01:25:05 PM


Document Has Been Signed on 02/15/2024 01:25 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:ALITI WAQALALAFACILITY TYPE:
740
ADDRESS:3612 EASTERN AVETELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
02/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:YELENA BIGELOW - ADMINISTRATORTIME COMPLETED:
02:00 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
Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required annual inspection visit. LPA met with administrator and stated the purpose of today’s visit. Administrator certificate expires 2/1/2025.

LPA and administrator toured and inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside backyard of the facility to ensure compliance with Title 22 regulations. The facility is licensed for four ambulatory residents and two non-ambulatory residents. There are currently five residents who reside at this facility. Common touch surfaces are cleaned after each use.

LPA measured the hot water temperature in resident's bathroom at 108.2 degrees Fahrenheit which is within the required range of 105 to 120 degrees. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Resident rooms were sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguisher was last inspected 10/9/2023. The last fire drill was on 1/23/2024. Facility has an emergency food and water kit.



LPA reviewed three resident files and three staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other who require caregiver background checks are Fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.

Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies cited during this visit.
Exit interview was held with administrator. A report and LIC 811(Confidential Names) was left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 1