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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 04/06/2022
Date Signed: 04/12/2022 04:34:21 PM

Document Has Been Signed on 04/12/2022 04:34 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 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:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lit TienTIME COMPLETED:
12:15 PM
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On 4/6/22 Licensing Program Analyst (LPA) Kevin Gould conducted a component III pre licensing meeting with Licensee Lit Tien via powerpoint presentation for Bella Hills Care Home. LPA Gould conducted the component III with the licensee.

LPA Gould discussed Operating Requirements, Physical Environment, Personnel Requirements, Resident Records, and Health Related Services and Conditions.

LPA discussed the department's and LPA's responsibilities and the responsibilities of the Administrator and reporting requirements including but not limited to the forms required for reporting and documenting any changes in resident files.

Exit interview was conducted.
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)
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