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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
342700919
Report Date:
05/30/2024
Date Signed:
05/30/2024 02:31:56 PM
Document Has Been Signed on
05/30/2024 02:31 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 CARE
FACILITY NUMBER:
342700919
ADMINISTRATOR:
LABELLA, MARK
FACILITY TYPE:
740
ADDRESS:
4082 73RD STREET
TELEPHONE:
(916) 594-7250
CITY:
SACRAMENTO
STATE:
CA
ZIP CODE:
95820
CAPACITY:
10
CENSUS:
7
DATE:
05/30/2024
TYPE OF VISIT:
Collateral
UNANNOUNCED
TIME BEGAN:
01:15 PM
MET WITH:
Theodora Patterson
TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a collateral visit. LPA Moleski met with staff member Theodora Patterson and explained the purpose of the visit.
LPA Moleski reviewed resident records and interviewed Patterson.
No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Patterson.
SUPERVISOR'S NAME:
Stephen Richardson
TELEPHONE:
(916) 263-4746
LICENSING EVALUATOR NAME:
Vincent Moleski
TELEPHONE:
(559) 365-5294
LICENSING EVALUATOR SIGNATURE:
DATE:
05/30/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/30/2024
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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