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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 01/09/2024
Date Signed: 01/09/2024 12:35:53 PM


Document Has Been Signed on 01/09/2024 12:35 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: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:
01/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Theodore Patterson TIME COMPLETED:
12:45 PM
NARRATIVE
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On 01/09/2024 at 8:20 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Theodore Patterson. A brief telephone call to administrator Mark Labella was conducted. LPA Lee explained to administrator the purpose of today’s visit. Direct care staff, Theodore Patterson assisted LPA Lee during the visit. LPA Lee explained the purpose of the visit to care staff. Administrator certificate # is 6028860740 and will expire on 07/29/2024. The current census is 8 with 2 facility staff. Administrator was not present during today’s visit.

This facility is a two-story building licensed to serve 8 non-ambulatory residents, 2 ambulatory residents in bedroom #5 only and approved for 1 hospice waiver. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA Lee observed resident 1 (R1) who is non-ambulatory in bedroom #5, which is fire clearance for only 2 ambulatory residents. Therefore, the facility did not adhere to the fire clearance and facility sketch. LPA Lee also observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured at 100.1 degrees Fahrenheit in the resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen and was last serviced on 01/04/2024. The last fire drill was conducted on 12/15/2023. LPA Lee observed the facility has a public telephone in the kitchen and the facility has the required posters posted.

Continued LIC 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4


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: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 01/09/2024
NARRATIVE
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Facility thermostat observed at 79 degrees Fahrenheit. LPA Lee observed toxins located in the kitchen and laundry room are both kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 4 out of 8 medication administration record (MAR) and it was not complete. LPA Lee observed (R2) Lipitor 40mg 8:00 PM medication was not marked as being given to residents from 01/01/2024 to 01/08/2024. Furthermore, it was also learned that while auditing the Lipitor 40mg medication (R2) had two extra pills left over which did not match with the start date of the medication. The first aid kit was checked and contained all the required components. LPA Lee requested residents and staff files for review. LPA Lee reviewed 5 out of 8 resident files and 3 out of 4 staff files and they were complete. LPA Lee reviewed staff criminal record clearances and 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.

The following documents will be email to LPA Lee (pang.lee@dss.ca.gov) by 01/16/2024 by 5:00 PM by end of day:

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An immediate civil penalty was assessed during today's visit. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 421IM, LIC 811 and Appeals rights were provided to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 01/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 01/09/2024 12:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(1)
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: (1) Nonambulatory persons.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above. The licensee did not maintain a fire clearance by having a (R1) non-ambulatory resident in bedroom #5 which is fire clearance and licensed for only ambulatory residents, which poses an immediate health, safety, or personal rights risk to persons in care.
POC Due Date: 01/12/2024
Plan of Correction
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Licensee will immediately remove (R1) from bedroom #5 and placed (R1) in a non-ambulatory room. Licensee will submit a statement of acknowledgment that the regulation cited today has been reviewed and understood. Licensee will submit POC to LPA Lee by 01/12/2023 by end of day 5:00 PM.

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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 01/09/2024 12:35 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/09/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care
(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following:
(4) The licensee shall assist residents with self-administered medications as needed.



This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews and record review, the licensee did not comply with the section cited above. The licensee did not maintain (R2) MAR log. (R2) Lipitor 40mg 8:00 PM medication was not marked as being given to residents from 01/01/2024 to 01/08/2024, which poses a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 01/23/2024
Plan of Correction
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Licensee will ensure that all facility staff are re-trained in administering and documenting medications when given to residents in care. Licensee will send LPA copies of staff training sign in sheets with facility staff signatures and the materials used for the training. POC will be emailed to LPA Lee by POC date 01/23/2024 by 5:00 PM end of day.
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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/09/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4