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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 01/30/2024
Date Signed: 01/30/2024 12:56:09 PM


Document Has Been Signed on 01/30/2024 12:56 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:
01/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Theodore Patterson 'TIME COMPLETED:
01:05 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 10:10 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by direct care staff Theodore Patterson and explained the purpose of today’s visit. The current census is 8 with 2 staff present in the facility. A brief telephone call was made to administrator Mark Labella in regard to POC.

The purpose of this visit is to follow-up on two plan of corrections that was due on 01/12/2024 and 01/23/2024. LPA Lee toured and inspected the facility to ensure the deficiencies previously cited on 01/09/2024 has been corrected. It was learned that resident 1 (R1) who is non-ambulatory is still residing in bedroom #5, which is licensed for 2 ambulatory residents only. Direct care staff, Theodore informed LPA Lee that the facility cannot moved (R1) to a different bedroom since all the residents in the other bedrooms are also non-ambulatory. During today’s visit, LPA Lee recited the facility due to POC not being corrected or an POC extension was not communicated to LPA Lee. During today’s phone call with administrator Mark, he explained that he is currently working on getting resident replace through Master Care and that he is also working with Metro Fire to get bedroom #5 clear for non-ambulatory. During 01/09/2024 annual visit, LPA Lee had explained to both administrator Mark Labella via telephone and to direct care staff Theodore what the options are in regard to the citations 87202(a)(1). Again, during today’s visit LPA Lee advised administrator Mark Labella and direct care staff Theodore what those options are. LPA Lee advised that administrator need to 1. Change the fire clearance, 2. Have resident moved to a non-ambulatory bedroom and 3. Find a new placement. POC was due on 01/12/2024; however, LPA Lee did not receive any communications from the administrator in regard to POC needing to be extended. Today, LPA Lee observed and learned that the census is 8 with only 1 ambulatory resident who is already in bedroom #5 with (R1); therefore, the administrator won’t be able to move any of the other residents to bedroom #5. On 01/09/2024 and today’s visit, LPA Lee observed two facilities sketches displaced on top of a piano.



Continued on 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: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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 3


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: 01/30/2024
NARRATIVE
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The first facility sketch showed resident bedroom #5 as an ambulatory room and the second facility sketch, which was behind the first facility sketch showed that resident bedroom #5 as a non-ambulatory bedroom. During today’s visit LPA Lee also advised administrator Mark that if for any reason he needs an extension on his POC it is his responsibility to notify the department.

Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87465(a)(4) has been cleared. The license did comply with the terms of the POC during today’s visit. During today’s visit administrator Mark asked LPA Lee to give him 10 minutes to send POC to LPA Lee email address.

2. Deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did comply with the terms of the POC and POC due date 01/12/2024 during today’s visit.

As a result of this POCl visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC-809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, 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: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/30/2024 12:56 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: 01/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/09/2024
Section Cited
CCR
87204(a)

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87204Limitations - Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time...

This requirement is not met as evidenced by:
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During today’s visit, LPA Lee advised the 3 options/plan of corrections that the licensee has. Licensee will provide LPA Lee a new facility sketch, which will reflect resident room #5, LIC 200 and complete 850 to change
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Based on observations, interviews and record review, the licensee did not comply with the section cited above. The licensee did not ensure that resident bedroom #5 is only for ambulatory resident. LPA Lee observed resident 1 (R1) residing in bedroom #5 who is non-ambulatory.
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fire clearance or continue to work with Master care in replacement or moved (R1) one to a non-ambulatory bedroom. Licensee will email LPA Lee POC by POC date 02/09/2024 by end of day 5:00 PM.

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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: 01/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3