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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 11/10/2022
Date Signed: 11/10/2022 12:55:15 PM


Document Has Been Signed on 11/10/2022 12:55 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:VITA BELLA ELDERLY CAREFACILITY NUMBER:
342700919
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 594-7250
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:10CENSUS: 9DATE:
11/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Una WqualalaTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Avelina Martinez arrived at facility unannounced to conduct a case management visit. LPA met with Una Wqualala and explained the purpose of the visit.

The purpose of the visit today, is in response to fire clearance deficiency, basic service deficiency and accepting a bedridden resident deficiency.


During today's visit, it was learned resident 1 (R1) is bedridden has not been moved from their bed for approximately three months. Moreover facility documents reports R1 is bedridden. Furthermore, the facility does not have a fire clearance for bedridden residents. As a result, A civil penalty is hereby assessed on today's date November 10, 2022 in the amount of $500.00. LPA Martinez toured the facility with staff and inspected smoke and carbon detectors and fire extinguishers on today's visit.

R1's Appraisal/Needs and Service Plan indicated R1 arrived at this facility in a bedridden state. Also, R1's resident appraisal states R1 is bed bound. A medical record dated May 5, 2022 stated R1 was confined to their bed and unable to get up from bed without assistance. LPA Martinez conducted an interview with R1, and R1 reported being bed bound and only being able to move their arms. As a result, the facility is operating beyond the conditions and limitations specified on the license.

In addition, R1's Health Certification form was not updated to reflect R1's ambulatory status. It was also learned the facility is unable to provide adequate care, as facility is not able to care for R1's mobility needs. R1's hoyer lift is not in good repair (broken), and staff are not able to transfer R1 on and off the bed. As a result, A civil penalty is hereby assessed on today's date November 10, 2022 in the amount of $500.00 for lack of basic care services.


Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
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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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: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 11/10/2022
NARRATIVE
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The facility will need to ensure fire clearance safety precautions are implemented. The facility is also in the process of relocating R1 to a skilled nursing facility. The facility will follow up with LPA Martinez daily in regards to R1's placement and R1's health condition.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code.


An exit interview was conducted, and a copy of the 809 report, civil penalty forms, and appeal rights were given to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/14/2022 08:37 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 11/10/2022 01:03 PM

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: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2022
Section Cited

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87204(b) Limitations - Capacity and Ambulatory Status: Resident rooms approved for 24-hour care of ambulatory residents only shall not accommodate nonambulatory residents...This requirement was not met as evidence by:
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Based on observation and file review, the licensee accepted a bedridden resident (R1). This poses an immediate health and safety risk to R1.
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Type A
11/10/2022
Section Cited

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87464(f) (1) Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This requirment was not met as evidence by: Based on observation and record review
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R1 is not being provided adequate basic care. This poses an immediate health and safety risk to R1.
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Facility staff agrees to train staff in regards to basic care and transferring by 11/10/22 Training documentation shall be emailed LPA Martinez by POC Date 11/10/2022.
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-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/10/2022 12:55 PM - It Cannot Be Edited

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: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/11/2022
Section Cited

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Fire Clearance 87202(a)(2) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department..Bedridden persons. This requirement is not met as evidence by: Based on observation and record review
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The facility admitted a bedridden resident. This poses an immediate health and safety risk to R1.
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Fire drill documentation shall be emailed to LPA Martinez by 11/11/2022. staff agrees to test all smoke and carbon detectors and inspect fire extinguishers by 11/11/22 and confirm completion of all tests and inspections to LPA Martinez by POC Date. 11/11/22. By email.

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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2022
LIC809 (FAS) - (06/04)
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