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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700922
Report Date: 10/10/2022
Date Signed: 10/11/2022 10:48:50 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220831124250
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: 6DATE:
10/10/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charlotte Lewis TIME COMPLETED:
11:00 AM
ALLEGATION(S):
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9
Staff did not properly maintain a resident's room
Resident's personal information was not properly safeguarded
Facility staff does not communicate effectively
Staff did not address a resident's needs while in care
Staff did not seek timely medical attention for a resident
Staff did not address a resident's change in medical condition

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/11/2022 at 9:00 am to deliver complaint findings, LPA met with Charlotte Lewis, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility documents. During a facility visit, LPA Martinez observed dust in resident 1's (R1) room. The dust build up was located on the window sill. LPA Martinez addressed the cleanliness issue with staff, and staff cleaned R1's window sill. Furthermore, the rest of the room was clean during the facility visit. It was also learned R1's personal property was not safeguarded. R1's responsible party requested for R1's personal property to be return to them. Facility staff informed R1' responsible party that they did not have the personal property in their possession. However, facility staff later found the property. After finding R1's personal property, the facility mailed R1's personal property to the responsible party.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220831124250

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: 3DATE:
10/10/2022
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Charlotte LewisTIME COMPLETED:
11:00 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Resident was denied access to the home
Resident's linens were not properly maintained while in care


INVESTIGATION FINDINGS:
1
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5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Avelina Martinez arrived at the facility unannounced on 10/11/2022 at 9:00 am to deliver complaint findings, LPA met with Charlotte Lewis, and explained the purpose of the visit.

Throughout the course of the investigation, LPA Martinez conducted interviews, toured the facility, and reviewed facility documents. Moreover, LPA Martinez reviewed the facility resident sign in and sign out log sheets. During the month of June 2022, resident 1 (R1) was signed out one time. However, R1 was not signed back into the facility. LPA Martinez interviewed staff 1 (S1), and S1 reported there were no complaints in regards to resident not being able to access the home. There is no evidence to prove this incident occurred, therefore, the allegation is unsubstantiated.

Continued...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 27-AS-20220831124250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700922
VISIT DATE: 10/10/2022
NARRATIVE
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Moreover, LPA Martinez observed R1's bed and linens. The bed and linens appeared to be clean. R1's shares their room with a roommate. LPA observed R1's roommate side of the room, and it was clean. There was not a preponderance of evidence to prove the linens were not clean and sanitary.

Due to the above noted information, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, and therefore the allegations are unsubstantiated.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 27-AS-20220831124250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700922
VISIT DATE: 10/10/2022
NARRATIVE
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Witness 1 (W1) has tried to get in contact with the facility Licensee since July 2022. W1 has left messages and sent emails to the Licensee. The Licensee has not returned any of W1 emails or phone calls. In addition, witness 2 (W2) has also attempted to get in contact with the Licensee, however, the Licensee has not contacted W2. LPA Martinez has also made attempts to contact the Licensee throughout the complaint investigation. It was not until September 29, 2022 that LPA Martinez received a return phone call from the Licensee. Moreover, a pre-scheduled Alta Regional Center meeting had to be rescheduled this month due to the Administrator not being able to attend. Additionally, the facility did not make other arrangement for the Licensee or other staff attend the Alta Regional Center's meeting. As a result, , it was determined the facility is not communicating effectively with responsible parties and agencies.

It was also learned the facility did not address residents needs while in care and did not initiate timely medical attention. R1 requires a Podiatrist to cut their toe nails, and this requirement was discussed at the July 2022 facility meeting with R1's Service Coordinator. During this meeting, it was agreed that facility staff would scheduled a Podiatrist medical appointment. However, during interviews, it was learned facility staff have not scheduled a Podiatrist appointment and have not addressed the toe nail issue. As of now, R1 has not had a Podiatrist appointment, and the facility has not address R1's toe nails change in condition.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations.. An exit interview was conducted, and copy of this 809 report, 809-D page, and appeals rights documents were provided 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: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 27-AS-20220831124250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87303(a)
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87303 (a) Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. This requirement was not met as evidence by: Based on observation R1's window sill was not in good repair and had dust build up.
1
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Facility cleaned R1's window sill during visit. Administrator agrees to conduct training on cleaning for all staff by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
8
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This posed an potential health and safety risk to R1.
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Type B
10/25/2022
Section Cited
CCR
87217(b)
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87217(b) Safeguards for Resident Cash, Personal Property, and Valuables: Every facility shall take appropriate measures to safeguard residents' cash resources, personal property and valuables which have been entrusted to the licensee or facility staff.
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The Administrator agrees to conduct training on safeguarding residents' property for all staff by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
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This requirement was not met as evidence by: Based on file review and interviews the facility did not safeguard R1's health insurance cards. This posed a potential health and safety risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 27-AS-20220831124250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87468.1(a)(9)
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87468.1 (a)(9) Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights...To have communications to the licensee from their representatives answered promptly and appropriately.
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Administrator agrees to conduct training on personal rights for all staff and Licensee by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
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This requirement was not met by evidence by: Based on interviews the Licensee did not ensure to communicate or return phone calls to R1's representatives. This posed a potential health and safety risk to R1.
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Type B
10/25/2022
Section Cited
CCR
87466
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87466 Observation of the Resident: The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs.
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Administrator agrees to conduct training on observation of residents for all staff and by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
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This requirement was not met as evidence by: Staff did not ensure resident's toe nails were not overgrown. This posed a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 27-AS-20220831124250
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 II
FACILITY NUMBER: 342700922
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/25/2022
Section Cited
CCR
87465(a)(2)
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87465 (a)(2) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility...The licensee shall provide assistance in meeting necessary medical and dental needs.
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Administrator agrees to conduct training on Incidental Medical and Dental Care for all staff and Licensee by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
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This requirement was not met as evidence by: Staff did not make an apt with a Podiatrist for R1. This posed a potential health and safety risk to residents in care.
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Type B
10/25/2022
Section Cited
CCR
87464(f)(1)
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87464 (f)(1) Basic Services: Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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Administrator agrees to conduct training on Basic Services for all staff and Licensee by POC date 10/25/2022. Administrator agrees to email LPA Martinez training document by POC Date 10/25/2022.
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This requirement was not met as evidence by: Based on interviews the facility did not ensure basic care and supervision was provided to R1 as R1 did not get medical treatment for fungus on her toes. This posed a potential health and safety risk to R1.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7