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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 02/24/2022
Date Signed: 02/24/2022 10:46:48 AM


Document Has Been Signed on 02/24/2022 10:46 AM - 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:TUIMAUALUGA, PENINAFACILITY TYPE:
740
ADDRESS:3612 EASTERN AVETELEPHONE:
(424) 345-0820
CITY:SACRAMENTOSTATE: CAZIP CODE:
95821
CAPACITY:6CENSUS: 5DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Penina TuimaualugaTIME COMPLETED:
11:00 AM
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Licensing Program Analysts(LPAs) Avelina Martinez and Maja Jensen made an unannounced visit to this facility to conduct an annual inspection on 02/24/2022 at 10:05 AM. LPA met with Penina Tuimaualuga and stated the purpose of today’s visit. LPAs inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations.

Administrator holds a current certificate. The facility is licensed for six non-ambulatory. There are currently 5 residents who reside at this facility. The facility has a hospice waiver for 1 resident. There are no residents receiving hospice services.

LPA Martinez and LPA Jensen toured the facility with Penina Tuimaualuga 02/24//2022 at 10:21 AM.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 postings throughout the facility. The facility has hand sanitizer throughout the facility, and has a supply of PPE. A LIC 808 Mitigation plan has been submitted to the Department. The facility furniture is spaced 6 feet apart, and has implemented social distancing practices.

The facility is disinfected daily. During the visit, the facility was sanitary. The facility water temperature was 105 degrees. The facility has a first aid kit. The facility smoke detectors and carbon detectors were in good repair. The facility fire extinguisher is in good repair. The facility has a 2 day supply of perishables and a 7 day of non-perishables. The exterior of the facility was sanitary. The facility side fence is not in good repair, and will be repaired on 02/25/2022. A technical violation was given for the broken fence.

The facility is in compliance with California Code of Regulations, Title 22 and Health and Safety Code, there were no deficiencies cited at this time. An exit interview was conducted, and a copy of this report was given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/24/2022
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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