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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 04/13/2023
Date Signed: 04/13/2023 11:36:36 AM

Document Has Been Signed on 04/13/2023 11:36 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: 4DATE:
04/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Chris Sinon, LicenseeTIME COMPLETED:
12:00 PM
NARRATIVE
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On 4/13/23 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Facility Name for the purpose of conducting a required 1 year annual inspection. LPA met with Licensee, Chris Sinon and together conducted a tour of the home.

LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed part of the fencing is in need of replacement due to rotting wood and possible wind damage. 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 106 degrees F which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. 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 is complete. LPA observed centrally stored medications secure from residents.

LPA reviewed all resident files and observed one resident has not been administered blood glucose monitoring via test strips since placement. The is allegedly due to an insurance issue with Kaiser. LPA reviewed files for all staff present and did not observe 8 hours of dementia care training. All other aspects of the staff files were complete and well organized.

LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 610E Emergency Disaster Plan, Current Administrator Certificate and Client Roster. Per California Code of Regulations, Title 22 the following deficiencies are cited during today's inspection. An exit interview was conducted, and a copy of this report and appeal rights were left at the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Kevin Gould
LICENSING EVALUATOR SIGNATURE: DATE: 04/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/13/2023
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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Document Has Been Signed on 04/13/2023 11:36 AM - It Cannot Be Edited


Created By: Kevin Gould On 04/13/2023 at 11:08 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: BELLA HILLS CARE HOME
FACILITY NUMBER: 342701140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of staff training files, the licensee did not comply with the section cited above for all staff files reviewed which showed no training specific to dementia care training. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/28/2023
Plan of Correction
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Facility agrees to have all staff receive 8 hours of dementia care training by the POC due date.
Type B
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA review of resident medication administration records, the licensee did not comply with the section cited above for one resident's blood glucose monitoring and the facility did not have a current supply of tests strips due to an insurance conflict. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2023
Plan of Correction
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licensee has agreed to obtain medication strips by the poc due date and begin administration.
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-Lee
LICENSING EVALUATOR NAME:Kevin Gould
LICENSING EVALUATOR SIGNATURE:
DATE: 04/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/13/2023


LIC809 (FAS) - (06/04)
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