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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 01/09/2023
Date Signed: 02/06/2023 07:27:53 AM


Document Has Been Signed on 02/06/2023 07:27 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: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: 8DATE:
01/09/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Gloria Clarke-Daily - Direct Care StaffTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced Required 1 Year Annual Inspection Visit. LPA was screened prior to being allowed entry into the home and explained purpose of visit to direct care staff.

LPA and direct care staff toured physical plant inside and outside to ensure the safety of the residents and compliance with Title 22 regulations. There were no observed health or safety concerns. LPA conducted the infection control domain tool. The facility has one central entry point and has implemented screening and sign in procedures at the front of the home. LPA observed the facility to have COVID-19 informational and hand washing signs posted at the front door and throughout the facility. The facility has seven (7) non-ambulatory and one (1) ambulatory residents. LPA observed the temperature inside the facility was measured at 72*F, which is within the required range of 68 degrees F and 85 degrees F. The hot water was measured at 110.3*F, which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations. Facility has nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA observed the centrally stored medications area and cleaning supplies to be locked and inaccessible to clients. Resident rooms was sanitary and had the required furniture and furnishings. The facility common areas were clean and furnished. Smoke and carbon detectors were in good repair. Fire extinguishers were last inspected on 4/31/2022.

LPA reviewed two (2) staff records and two (2) resident records. All files were complete. Staff are fingerprint cleared and first aid certified. Liability Insurance expires 3/1/2023.
LPA observed medications and the MARS sheets. Medications appear to be documented appropriately.

LPA requested the following updated documents to be emailed by February 6, 2023: Administrator Certificate, Liability Insurance, LIC 308 - Designation of Administrative Responsibility, and LIC 610-E Emergency Disaster Plan.

 Per California Code of Regulations, Title 22, Division 6, Chapter 8, no deficiencies were observed during this visit.
An exit interview was held with direct care staff and a copy of the report was left at facility.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 253-4746
LICENSING EVALUATOR NAME: Ruth WallaceTELEPHONE: (619) 323-4509
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2023
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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