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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 10/31/2022
Date Signed: 10/31/2022 10:54:47 AM


Document Has Been Signed on 10/31/2022 10:54 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: 4DATE:
10/31/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Penina Tuimaualuga TIME COMPLETED:
11:00 AM
NARRATIVE
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On 10/31/2022, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit at 9:30 AM. LPA Martinez met with Penina Tuimaualuga and explained the purpose of the visit.

The purpose of the visit today is to discuss Administrator concerns. LPA Martinez conducted a case management visit 10/11/2022, and requested the Licensee to assign a qualified Administrator to this facility. The facility currently does not have a qualified assigned Administrator. As a result of this visit, the facility was cited on today's visit. The Licensee agreed to assign a qualified Administrator by 11/04/2022 close of business 5 PM. the following documents were requested:
  1. LIC 500 Personnel Schedule
  2. LIC 308 Designation of Facility Responsibility
  3. LIC 501 Employee Application
  4. Administrator Certificate
  5. Education Background

The Licensee agreed to email documents by 11/04/2022 close of business 5 PM.

LPA Martinez also followed up on resident 1's P & I payment to this facility. The facility received a $200.00 P&I payment for R1, which the facility does not have P&I records. The facility also does not have surety bonding insurance.

As a result of this visit, the following deficiencies were cited, per Title 22 Regulations. The deficiencies can be found on the 809-D Page. An exit interview was conducted, and copy of this 809 report, 809-D page, and appeals rights were 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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/31/2022 10:54 AM - 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
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/04/2022
Section Cited

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87405(a) Administrator - Qualifications and Duties: All facilities shall have a qualified and currently certified administrator... This requirement was not met as by evidence. Based on record review, interviews, and observation, there was not an assigned Administrator on 10/31/2022 visit.
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This posed a potential health and safety risk to residents in care.
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Type B
11/14/2022
Section Cited

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Safeguards for Resident Cash, Personal Property, and Valuables: 87217(g) Each licensee shall maintain adequate safeguards and accurate records of cash resources and valuables entrusted to his care. This requirement was not met as evidence by.
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Based on record review the facility did not have P&I documentation. 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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 10/31/2022 10:54 AM - 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
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: 10/31/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/14/2022
Section Cited

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Bonding 87216(a) Each licensee, other than a county, who is entrusted to safeguard resident cash resources, shall file or have on file with the licensing agency a copy of a bond issued by a surety company to the State of California as principal.
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This requirement was not met as evidence by: based on interviews, the Licensee reported the facility did not have a surety bonding for R1's P&I money. 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: 10/31/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3