342700922-1-11-2024-27-AS-AMAZ-CZDVRH-20240111153958

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 01/11/2024
Date Signed: 01/11/2024 03:40:07 PM

Document Has Been Signed on 01/11/2024 03:40 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 II		FACILITY NUMBER:	342700922
ADMINISTRATOR:	ALITI WAQALALA		FACILITY TYPE:	740
ADDRESS:	3612 EASTERN AVE		TELEPHONE:	(424) 345-0820
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95821
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	01/11/2024
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Yelena Begelow		TIME COMPLETED:	03:45 PM

NARRATIVE

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Licensing Program Analysts (LPA)s Avelina Martinez and Jamie Ivey Canady conducted an unannounced visit to the facility on 1/11/2024. LPAs met with current facility administrator, Yelena Bigelow, and explained the purpose of today's visit.

The purpose of the visit is to follow up learned deficiencies during a pre-licensing visit on 01/11/2024. Please see 01/11/2024 pre licensing visit report for additional information.

Based on LPAs observations, facility is currently understaffed. Staff 1 comes to the facility on Friday morning at 8 am and stays until Saturday 9pm. Staff 2 is a live in caregiver and works Saturday 9pm until Friday Morning at 8am. Based on facility staff interviews, there is no awake staff at night. Residents are left unsupervised during live-in staff sleeping hours.

According to staff, resident 1 is not able to stand up on their own or bare weight on their feet. In addition, staff reported resident 1 is left in their bed due to being a 2 person care assist. Moreover, the facility does not have a bed ridden fire clearance. In addition, LIC 602 physician report is missing pages, and is not complete. At this time there is no documentation stating resident 1 is bed ridden. Facility shall conduct reassessments for all residents and obtain LIC 602 physician reports for all residents. LPAs will follow up on bed ridden clearance issue.

Rooms 2 and 6 door to the outside do not lock from the inside, and doors will automatically lock from the outside, which residents will not be able to re-enter their room from the outside. In addition, facility staff did not have keys for room door 2 and room door 5.

Continued...

Liza King	TELEPHONE: (650) 676-0442
Avelina Martinez	TELEPHONE: (916) 431-8935
	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.

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/11/2024 03:40 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

87705 Care of Persons with Dementia(a) This section applies to licensees who accept or retain residents diagnosed by a physician to have dementia...(A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake...This was not met as evidenced by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator agrees to submit Awake care staff work schedule by 01/12/24 8:00 AM. Email work schedule to LPA Ivy-Canady In addition to, to scheduling an awake staff immediately as of today.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Liza King	TELEPHONE: (650) 676-0442
Avelina Martinez	TELEPHONE: (916) 431-8935
	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

LIC809 (FAS) - (06/04)

Page: 3 of 4

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: 01/11/2024

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The current assigned Administrator, Yelena Bigelow, is appointed to another facility, and spends 20 hours a week at Bella Villa Elderly 2 Care Facility. Due to facility immediate health and safety concerns, LPA Martinez has requested that an administrator be at Bella Villa Elderly Care 2 facility 40 hours a week. An informal conference meeting will be scheduled to address the health and safety concerns and Administrator hours. LPAs will provide further information to Licensee, applicant, and administrator regarding scheduling informal conference meeting. Administrator qualifications citations can be found on the 809-D page. An awake care staff schedule and LIC 500 works schedule report will need to be submitted to Community Care Licensing Department by 8:00 AM.

An exit interview was conducted, and a copy of this report, 809-D page, and appeals rights were provided to the facility.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
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

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/11/2024 03:40 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Deficiency Dismissed

Section Cited

87458(a) Medical Assessment Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year... This requirement was not met as evidence by
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Administrator requested LIC 602 for R1 during today's visit. Email Ivy-Canady LIC 602 status from doctor by 01/12/24 5:00 PM

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Liza King	TELEPHONE: (650) 676-0442
Avelina Martinez	TELEPHONE: (916) 431-8935
	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

LIC809 (FAS) - (06/04)

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