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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701140
Report Date: 04/23/2026
Date Signed: 04/23/2026 02:29:06 PM

Document Has Been Signed on 04/23/2026 02:29 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/
DIRECTOR:		TIEN, LIT A.FACILITY TYPE:
740
ADDRESS:8579 TRAYNOR WAYTELEPHONE:
(916) 687-1207
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 4CENSUS: 3DATE:
04/23/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Jose Ernesto Pasion TIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On April 23, 2026, Licensing Program Analyst, Arvin Villanueva (LPA), arrived unannounced at this facility to conduct the annual inspection visit. LPA Initially met with staff on duty, Richard Baltazar (S1) and stated the purpose of the visit. The administrator, Lit Tien (AD) was notified and unable to be present today. Facility supervisor, Jose Ernesto Pasion (S2), arrived shortly after and assisted with the inspection.
Overview: Facility is a one-story building located in a residential neighborhood. Facility is licensed to serve up to 4 elderly residents, 2 of which may be non-ambulatory. Facility does manage residents’ cash resources. Facility does not have clearance for bedridden, delayed egress, and/or locked interior/exterior.
Physical Inspection: Areas inspected include, but not limited to, the kitchen, resident bedrooms, resident bathrooms, living and dining room and outdoor areas.
LPA inspected 4 of 4 resident bedrooms and 2 of 2 bathrooms. In Bedroom #1 of the facility sketch, the exit door to the outside did not have proper ramp, as the height of the ramp is more than half an inch down. Advisory given to obtain appropriate ramp. Room temperature was maintained at 68 degrees F. The hot water temperature was measured at 117 degrees Fahrenheit. Smoke and carbon monoxide detectors were observed throughout.
In the kitchen, the facility maintained at least a seven-day supply of non-perishable foods and a two-day supply of perishable foods. However, LPA observed only 3 kinds of fruits (banana, strawberries, oranges). LPA did not observe fresh vegetables in the refrigerator. Per interview with S1 and S2, they serve canned vegetables as preferred by residents in care. S2 confirmed there is no documentation that indicates their residents’ food preferences. Per review of the menu, vegetables are included. One fire extinguisher was observed in the kitchen area. Sharp objects were in a locked drawer. Cleaning solutions and dish soaps were in a locked cabinet under the sink.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/23/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/23/2026 02:29 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/23/2026 at 01:07 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLA HILLS CARE HOME
FACILITY NUMBER: 342701140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. The exit door at the kitchen/dining area did not have a ramp which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Corrected on site: staff placed a ramp at the exit door.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Inspection of the refrigerator in the garage, LPA observed 2 bottles of Pepto Bismol that are accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/24/2026
Plan of Correction
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Corrected on site: staff immediately removed these medications and placed them inside the locked medication cabinet.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
Page: 3 of 12
Document Has Been Signed on 04/23/2026 02:29 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/23/2026 at 01:07 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLA HILLS CARE HOME
FACILITY NUMBER: 342701140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed a laundry detergent in an unlocked cabinet in the garage that was accessible to residents in care which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Corrected on site: staff immediately removed the detergent and place it in a locked storage.
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. During an inspection of food supply, LPA only observed 3 kinds of fruits and no fresh vegetables in the fridge, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Per discussion, admin agreed to provide a written plan of correction on the specific steps the facility will take to ensure the facility maintains an adequate supply of perishable foods (including vareity of fresh fruits and vegetables) to meet the needs of residents, which include documentaion of residents' food preferences and diet orders.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
Page: 4 of 12
Document Has Been Signed on 04/23/2026 02:29 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 04/23/2026 at 01:07 PM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: BELLA HILLS CARE HOME
FACILITY NUMBER: 342701140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/23/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.39(b)
Regulations
(b) A residential care facility for the elderly that accepts or retains residents with restricted health conditions, as defined by the department, shall ensure that residents receive medical care as prescribed by the resident’s physician and contained in the resident’s service plan by appropriately skilled professionals acting within their scope of practice. An appropriately skilled professional may not be required when the resident is providing self-care, as defined by the department, and there is documentation in the resident’s service plan that the resident is capable of providing self-care.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the licensee did not comply with the section cited above. In one resident record review, resident has an injectable medication but facility did not develop a health care plan prior start of the medication, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/30/2026
Plan of Correction
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Per discussion, administrator agreed to develop a restricted health care plan as per regulation and submit plan to the Department by POC due date.
Admin was advised to contact LPA if more time is needed.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Arvin Villanueva
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/23/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2026


LIC809 (FAS) - (06/04)
Page: 5 of 12
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: 04/23/2026
NARRATIVE
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Laundry room was inspected. Laundry soaps and hygiene supplies were observed to be locked in cabinet. The garage area was not locked. Inside the garage, LPA observed a laundry detergent in one of the cabinets that can be accessed by residents in care. The garage also has a refrigerator; inside this refrigerator, LPA observed 2 bottles of Pepto Bismol and are accessible to residents in care.
Outdoor area was inspected. LPA observed covered areas with outdoor furniture. Ramps, fence, and exit gate were observed to be in good repair at this time. At the kitchen/dining exit door, going to the patio at the back, LPA observed the ramp to be missing. For shut off valves, initially, S2 was unable to locate the location of the electric and gas shut off valves until he called the AD. Per S2, he does not know how to operate the gas shut-off valves.
Record Reviews: Review of 4 of 4 resident files was conducted, including but not limited to, review of Admission Agreement, Physician Reports, Needs and Services Plan, Centrally Stored Medication Record and Ambulatory Status. PRN Authorization Letter was on file for each resident.
Medication reviews were conducted for 2 residents. For residents that require injection treatment, they did not have Restricted Health Care Plan in place prior to retaining those residents.
Cash (P&I) records were reviewed for 3 residents. Staff counted 3 residents’ money in front of LPA.
Review of 4 staff files included but not limited to background clearance, first aid/CPR certification, and training.
Emergency Procedures Plan and Infection Control Plan were reviewed. Facility conducts monthly disaster/fire drills. Reminders were provided to review their plans at least annually. Staff tested one of the smoke/carbon monoxide detectors and were found to be operable.
Documents Requested: LPA requested a copy of updated Liability Insurance Certificate, Surety Bond, LIC500, and LIC308.
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, deficiencies were cited and advisories were provided. An immediate Civil Penalty was assessed today in the amount of $500 due to fire clearance violation by removing the ramp at the exit door in the kitchen/dining area.
Plan of corrections were discussed during exit interview was with Jose Ernesto Pasion. A copy of the report and appeal rights were provided upon exit.
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NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Arvin Villanueva
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/23/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2026
LIC809 (FAS) - (06/04)
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