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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700919
Report Date: 11/17/2022
Date Signed: 11/17/2022 09:49:43 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220919162038
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:
11/17/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Una WqualalaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff are not providing appropriate care and supervision to a resident.
Staff are not seeking timely medical attention for a resident.
Resident is not provided comfortable accommodations while in care.
INVESTIGATION FINDINGS:
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On 11-17-2022 at 8:30 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegations. LPA Martinez met with Una Wqualala and explained the purpose of today's visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. During the complaint investigation, it was learned resident 1 (R1) has a bedridden status. Moreover, it was reported R1 has not been transferred out of their bed for approximately three months. Facility care staff are not able to meet R1's mobility care needs due to not having durable medical equipment and weight.

Continued...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 27-AS-20220919162038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/17/2022
NARRATIVE
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During this investigation, it was determined the facility did not seek timely medical attention for R1's mobility care needs. The facility staff did not initiate the replacement of R1's hoyer lift and did not seek medical attention after acknowledging their inability to meet R1's mobility needs. Additionally, the facility did provide comfortable accommodation, as the facility was not able to provide adequate mobility care to R1 resulting in R1 not be transferred out of their bed and being confined to their bed.

Basic Care deficiency was cited on November 10, 2022, and a plan of correction (POC) was implemented. Therefore, Basic Care citation will not be cited on this complaint. Please see November 10, 2022 case management for the citation. Moreover, an immediate and health and safety risk civil penalty was given on November 10, 2022.

As a result of this investigation, the Department finds these allegations to be Substantiated. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the evidence standard has been met. Deficiencies cited on the LIC 9099-D page, per Title 22 Regulations.

An exit interview was conducted, and a copy of the 9099 report, LIC 9099-D page, 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: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20220919162038
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/17/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2022
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations... This requirement was not met as evidence by:
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Facility staff agrees to conduct personal rights training for all staff, by POC Date 11/18/2022. Facility Staff agrees to email training documents to LPA Martinez by POC date 11/18/2022.
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Based on observation and file review, the facility did not provide a safe and comfortable accommodation to R1, as staff were not able to transfer R1 out of bed and was confined to their bed. This posed an immediate health and safety risk to R1.
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Type A
11/18/2022
Section Cited
CCR
87465(a)(2)
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87465(a)(2) Incidental Medical and Dental Care: A plan for incidental medical and dental care shall be developed by each facility. The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement was not met as evidence by:
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Facility staff agrees to conduct change in health conditions training and training on reporting health changes to Administrator/Licensee and primary care physicians training to all staff
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Based on observation and file review, the facility was not able to meet R1's mobility care needs, and did not develop a plan to meet R1's mobility needs and did not follow up with R1' hoyer lift needs. This posed an immediate health and safety risk to R1.
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by POC Date 11/18/2022. Facility Staff agrees to email training documents to LPA Martinez by POC date 11/18/2022.
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: 11/17/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/19/2022 and conducted by Evaluator Avelina Martinez
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20220919162038

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:
11/17/2022
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Una WqualalaTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff are not ensuring a resident is attending physical therapy
INVESTIGATION FINDINGS:
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On 11-17-2022 at 8:30 am, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA Martinez met with Una Wqualala and explained the purpose of today's visit.

Throughout the course of the investigation, LPA Martinez conducted interviews and reviewed facility files. During the complaint investigation, it was learned resident 1 (R1) was discharged from Home Health services. R1's Home Health services started in November of 2021 and services ended in May 2022. Also, staff 1 (S1) reported conducting exercises with R1, which consist of arm movement. R1 also demonstrated how they are able to exercises their arms only. In addition, LPA Martinez reviewed R1's file did not find a physical therapy order. Due to the above noted information, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted and a copy of this report was provided to the facility.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4