<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:06:03 AM


Document Has Been Signed on 01/12/2023 11:06 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:
01/12/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Joseph DouglasTIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 01/12/2023, 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 P&I and reimbursement records for resident 1 (R1). The facility was cited on 10/31/2022 in regards to P&I and reimbursement records, and an implemented POC was to reimburse R1 $200.00. As a result of not correcting the POC, the facility will be re-cited. The facility shall email LPA Martinez P&I and reimbursement records by 01/13/2023

In addition, LPA Martinez also followed up on the proposed Administrator status. It was learned the current administrator is also the Administrator for Abounding Love 2 facility. LPA Martinez requested an LIC 500 facility staff schedule for Abounding Love 2 and Bella Villa 2. Facility Staff schedules shall be emailed to LPA Martinez on 01/12/2023 by 5PM.

As a result of this visit, the following deficiency was cited, per Title 22 Regulations. The deficiency 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: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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 2


Document Has Been Signed on 01/12/2023 11:06 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: 01/12/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited

1
2
3
4
5
6
7
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.
1
2
3
4
5
6
7
Facility staff agrees to email LPA Martinez P&I Records and reimbursement Records to LPA Martinez by 01/13/2023.
8
9
10
11
12
13
14
Based on record review the facility did not have P&I documentation. This posed a potential health and safety risk to residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 01/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2