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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 03/09/2022
Date Signed: 03/09/2022 10:55:52 AM

Document Has Been Signed on 03/09/2022 10:55 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814
FACILITY NAME:BELLA HILLS CARE HOMEFACILITY NUMBER:
342701140
ADMINISTRATOR:TIEN, LIT A.FACILITY TYPE:
740
ADDRESS:8579 TRAYNOR WAYTELEPHONE:
(916) 687-1207
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: DATE:
03/09/2022
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Lit Tien & Khan TienTIME COMPLETED:
10:30 AM
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Facility Type: RCFE
Application Type: Initial
Capacity: 4
Census (if any clients in care): zero
Method: Telephone call with applicant
COMP II Participants: Lit Tien & Khan Tien

Applicant/administrator participated in COMP II via telephone call with the analyst at CAB. Identification of the applicant and administrator was verified by photo ID. During COMP II, applicant and administrator confirmed the understanding of Title 22. Component II was successfully completed. Applicant has been advised to transmit signed LIC 809 with copy of photo ID to CAB.
SUPERVISORS NAME: Julia Kim
LICENSING EVALUATOR NAME: Dianne Ramos
LICENSING EVALUATOR SIGNATURE: DATE: 03/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/09/2022
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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