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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 04/06/2022
Date Signed: 04/06/2022 11:59:14 AM

Document Has Been Signed on 04/06/2022 11:59 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 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: 0DATE:
04/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lit TienTIME COMPLETED:
10:30 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 4/6/22 at 8:30am Licensing Program Analyst (LPA) Kevin Gould arrived at Bella Hills Care Home for the purpose of conducting a pre-licensing inspection and ensure the facility is ready to be licensed. LPA met with applicant, Lit Tien and together conducted a tour of the home. The facility is a single story home located in a residential neighborhood. The home is equipped with four (4) bedrooms, two (2) bathrooms, kitchen, living room, dining room, family room and laundry room. The house is also equipped with an attached two car garage.

LPA and applicant evaluated the physical plant to ensure no hazards presented health and safety risk of the residents in care. Areas inspected are including but not limited to the kitchen, bedrooms, bathrooms, living and dining room and outdoor areas. LPA observed the back yard to have a covered patio area but no available outdoor seating for residents. LPA also observed the backyard fence along the right side of the home that has boards that have detached from the fencing and requires repair. LPA observed the facility to be free of odor and clean. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility.

LPA measured the water temperature, temperature measured at 108 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient food supplies to meet the needs of residents. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and needs one pair of tweezers. LPA observed secured medication storage space in the kitchen. LPA observed that both bathrooms require a covered trash can.

The following is needed before LPA Gould can approve facility for licensure:
1) Covered trash cans in both bathrooms
2) fence repair along right side of home
3) Patio/outdoor furniture to meet capacity
4) tweezer for first aid kit.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2022
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 2
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 HILLS CARE HOME
FACILITY NUMBER: 342701140
VISIT DATE: 04/06/2022
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
26
27
28
29
30
31
32
LPA Gould has scheduled a follow up pre-licensing inspection for Wednesday 4/13/22 at 9:00am.

Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE:

DATE: 04/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/06/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2