<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 02/15/2024
Date Signed: 02/15/2024 12:16:04 PM


Document Has Been Signed on 02/15/2024 12:16 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: 7DATE:
02/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
10:48 AM
MET WITH:Walesi VakararawaTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 02/15/2024 at 10:45 AM, to conduct an unannounced Plan of Correction (POC) visit. LPA met with care staff, Walesi Vakararawa and explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due on 02/09/2024. The census is 7. 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.

On 01/09/2024, during an annual inspection, LPA Lee observed resident 1 (R1), who is non-ambulatory was residing in resident bedroom #5, which is licensed for two ambulatory residents only. On 01/30/2024, LPA Lee conducted a POC visit and POC was not cleared; therefore, LPA Lee recited the facility. On 02/07/2024, LPA Lee received an email from direct care staff Theodore Slypher informing LPA Lee that On 02/06/2024, Purls Placement Agency had moved (R2) out of the facility; therefore, (R1) has been moved to the vacant resident bedroom#3. During today’s visit, LPA Lee observed (R1) is now residing in room #3 which is licensed for two non-ambulatory residents. LPA Lee also observed resident bedroom #5 has (R3) residing in the room, who is ambulatory. On 01/09/2024 Annual Visit, it was learned that per the direction of the Metro Fire the licensee was required to put a fire door prior entering the hall way to the residents bedrooms. During today's visit, LPA Lee informed administrator, Mark Labella that he will need to update and submit to the department a new facility sketch that reflects the fire door that was placed.

Based upon this inspection, the LPAs observed the following:

1. The deficiency cited under Title 22 Regulation 8720(a) has been cleared. The licensee complied with the terms of the POC by POC date of 02/09/2024. A POC letter was generated and provided to the licensee.

An exit interview was conducted and a copy of this report LIC 809, LIC 811 and POC letter was given to care staff, Walesi Vakararawa.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024
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 1