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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700922
Report Date: 02/06/2023
Date Signed: 02/06/2023 01:19:54 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 02/06/2023 01:19 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:
02/06/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:11 AM
MET WITH:Penina TuimaualugaTIME COMPLETED:
01:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual inspection on 02/06/2023 at 11:11 AM. LPA met with Penina Tuimaualuga and stated the purpose of today’s visit. LPA 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 current certificate and expires on 06/16/2023. The facility is licensed for six non-ambulatory residents. There are currently four residents who reside at this facility. The facility has a hospice waiver for one.

LPA Martinez toured the facility with Penina Tuimaualuga on 02/06/2023 at 12:00 PM.



The facility has one Covid-19 screening entry point, and sign in sheet. 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. LPA Martinez reviewed three resident files and two staff files. Resident and staff files were not complete. Staff 2 (S2) file was missing health certification form and resident 2 (R2) was missing a TB information on LIC 602, and the file did not contain any other TB document. The facility has a first aid kit, and medications are locked. The smoke and carbon detectors are in good repair. The facility fire extinguisher was last inspected on October of 2022. The last fire drill was in December of 2022. The emergency exterior gate was in good repair. LPA Martinez observed toxins in an unlocked cabinet, and staff removed the toxins. Facility staff put them in the locked laundry area.

As a result of this annual visit, deficiencies can be found on the 809D Page. An exit interview was conducted, and a copy of the 809 report, 809D page, and appeals rights 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: 02/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
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 3


Document Has Been Signed on 02/06/2023 01:19 PM - 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: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/20/2023
Section Cited

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87458(b)(1)Medical Assessment:The medical assessment shall include, but not be limited to: A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for examination for communicable tuberculosis
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The Administrator agrees to obtained TB documentation for R1 by POC Date 02/20/23. The Administrator will email TB documentation to LPA Martinez by POC date 02/20/23 by close of business 5 PM.
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This requirement was not met as evidence by: based on observation and file review R1 did not have TB screening information on the LIC 602 and no other documents on TB results. 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: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 02/06/2023 01:19 PM - 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: 02/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/07/2023
Section Cited

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87309(a) Storage Space:Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by. Based on observation and inspection
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Facility staff removed toxins from unlocked cabinet during today's visit. Licensee agrees to fix broken lock on the toxins cabinet by POC Date 02/07/2023. Licensee agrees to email LPA Martinez a picture of fix toxins cabinet lock by POC date 02/07/2023 by 5 PM.
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The Licensee did not ensure S2 had a health screening document. This posed a potential health and safety risk to residents in care.
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Type B
02/20/2023
Section Cited

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Personnel Records 87412(a)(11)the licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee...A health screening as specified in Section 87411. This requirement was not met as evidence by: Based on observation and file review.
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The Licensee agrees to provide health screening document to LPA Martinez via email by POC date 02/20/23 close of business 5 PM.
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The Licensee did not ensure S2 had a health screening document. 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: 02/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3