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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 09/01/2023
Date Signed: 09/01/2023 02:58:25 PM

Document Has Been Signed on 09/01/2023 02:58 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
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:
09/01/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Marjorie EstoestaTIME COMPLETED:
03:15 PM
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On 09/01/2023 at 12:30 PM, Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced to conduct a post-licensing inspection. LPA Lee arrived and was greeted by Caregiver, Marjorie Estoesta. LPA Lee asked Caregiver to contact the Facility Designated Administrator (FDA) to let them know that CCL was present at this time. House Manager, Christophe Sinon called the facility and spoke to LPA Lee informing LPA Lee that the facility administrator Lit Tien is not available, and that care staff Marjorie Estoesta can conduct and signed the post-licensing visit documents. The census is 4 clients and 1 facility staff. Administrator Lit, Tien arrived approximately two hours later and completed the visit with LPA Lee.

LPA Lee met with caregiver, Marjorie Estoesta and explained the purpose of the visit. Administrator Certificate # 6045419740 expires 10/04/2023. LPA toured and inspected the physical plant inside and outside with care staff to ensure there were no health and safety concerns. LPA observed the kitchen, bedrooms, bathrooms, and common areas. LPA observed the facility is in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed the rooms to be clean and organized with comfortable furnishings. The hot water temperature was measured at 112.5 degrees Fahrenheit. The temperature inside the facility measured at 74 degrees Fahrenheit which was within the required range of 68-85 degrees Fahrenheit. LPA observed supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days maintained on the premises. LPA observed the centrally stored medication areas to be locked and made inaccessible to the residents at this time. LPA observed the fire extinguisher, and first aid kits were up to date. LPA observed smoke and carbon monoxide detector(s) in the facility were in good repair. LPA Lee observed the following poster posted in the entrance of the facility, “See Something Say Something poster,” however, the poster was the incorrect size.

Report continued on 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/01/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: BELLA HILLS CARE HOME
FACILITY NUMBER: 342701140
VISIT DATE: 09/01/2023
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LPA reviewed (3) resident files and (2) staff files and they were complete. LPA Lee reviewed 2 out of 4 MARS and it was complete. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Per California Code of Regulations, Title 22, no deficiencies were observed during today’s visit. A copy of this report was provided to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/01/2023
LIC809 (FAS) - (06/04)
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