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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 02/21/2024
Date Signed: 02/23/2024 04:32:14 PM


Document Has Been Signed on 02/23/2024 04:32 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:
02/21/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Penina Tuimaualuga, Yelena Bigelow, Lustina MigneaTIME COMPLETED:
11:30 AM
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A Non-Compliance Conference (NCC) was conducted today on February 21, 2024 via Microsoft Teams with the Sacramento South Regional Office. Present at today's meeting include the following: Licensing Program Manager Stephenie Doub, Licensing Program Manager Czarrina Camilon-Lee, and Licensing Program Analyst Avelina Martinez, and Licensing Program Analyst Jamie Ivey-Canady: Facility Representatives: Penina Tuimaualuga Licensee, Yelena Bigelow Administrator and Lustina Mignea Attorney.

The non-compliance conference process was explained during this meeting to include the Administrative process.


Issues discussed during the Non-Compliance Conference were:
1. Resident Assessments

2. Physical Plant - Facility locks, ramps and backyard repairs

3. Notice properly provided to residents

4. Documentation verifying residents provided notice

5. Application change until residents have been given 30 day notice

6. Appropriate staffing for resident care needs possible 2 person assist with ADLs

Cont on 809C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:
DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/21/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/21/2024
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Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:
-Licensee to provide the Department with updated LIC602s for all residents NLT 2/28/2024

-Licensee to provide the Department with admission agreements and reassessments for all residents NLT 2/28/2024

-Licensee to provide the Department with documentation and photographs showing completion of work regarding cement slabs in facility backyard

-Licensee to provide the Department with an updated and current LIC500 showing staff to resident ratio based on facility staff care and needs

-Licensee to provide date stamped notification documents alerting each resident of change of ownership and resident rights
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Jamie Ivey-CanadyTELEPHONE: (916) 862-5693
LICENSING EVALUATOR SIGNATURE:

DATE: 02/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2024
LIC809 (FAS) - (06/04)
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