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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 11/10/2022
Date Signed: 11/10/2022 02:56:09 PM


Document Has Been Signed on 11/10/2022 02:56 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
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:
11/10/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Joseph DouglasTIME COMPLETED:
03:05 PM
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On 11/10/2022, Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Joseph Douglas and explained the purpose of the visit.

The purpose of the visit today is to discuss the proposed Administrator documentation. During the visit, LPA Martinez spoke with Penina via phone call in regards to the requested Administrator documents. LPA Martinez was informed the requested documents would be emailed by today at 5 PM. However, a $600.00 civil penalty has been assessed on today's date 11/10/2022 due to not submitting POC documents by the POC date 11/04/2022.

The requested documents are:

  1. LIC 500 Personnel Schedule
  2. LIC 308 Designation of Facility Responsibility
  3. LIC 501 Employee Application
  4. Administrator Certificate
  5. Education Background

An exit interview was conducted, and a copy of this 809 report, civil penalty, 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: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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