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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700922
Report Date: 04/03/2024
Date Signed: 04/03/2024 02:02:44 PM

Unsubstantiated


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
01/08/2024 and conducted by Evaluator Tung Truong
COMPLAINT CONTROL NUMBER: 27-AS-20240108090435
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:0CENSUS: 0DATE:
04/03/2024
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Facility was closed on 3/19/24TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff did not provide adequate supervision resulting in resident pushing another resident and causing a fracture.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Tung Truong attempted to contact the licensee to deliver the complaint findings due to the facility closure on 3/19/2024 .

Throughout the course of the investigation, the Department conducted interviews and reviewed records. Based on records review, and staff and resident interviews, there is not a preponderance of evidence to substantiate the allegation mentioned above. The investigation revealed that resident (R1) had never shown signs of physical/verbal aggression towards resident (R2). Other residents were unable to confirm that they knew who R1 and R2 were and were unaware of the incident. R2 was unable to corroborate how they sustained their fall.

Continued on 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
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 2
Control Number 27-AS-20240108090435
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: 04/03/2024
NARRATIVE
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As a result of this investigation, the Department finds these allegations to be Unsubstantiated. A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred.

A copy of this report will be certified mail to the licensee's address.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2