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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700919
Report Date: 06/24/2024
Date Signed: 06/24/2024 03:29:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/23/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240523091818
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:
06/24/2024
UNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Kirk CampbellTIME COMPLETED:
03:48 PM
ALLEGATION(S):
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Staff are not dispensing medications as prescribed.
Staff do not assist resident with attending medical appointments.
Staff are not properly supervising resident.
INVESTIGATION FINDINGS:
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On 06/24/2024 at 3:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff Kirk Campbell and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 8 with 1 facility staff. During today's visit, LPA Lee called administrator Mark Labella and left a message. Administrator was not present during today's visit. A brief interview with conducted with care staff Kirk.

Allegation: Staff are not dispensing medications as prescribed.
It was alleged that staff are not dispensing medications as prescribed. This investigation consisted of interviews with staff and residents. LPA Lee interviewed 1 out of 6 residents who has concerned with not getting medications. LPA Lee also interview 2 out of 2 facility staff who denied the allegation. Based on residents Medication Administration Log (MAR) it was learned that 3 out of 4 resident’s MAR logs are incomplete.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 27-AS-20240523091818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2024
NARRATIVE
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. Resident 2 (R2) is missing initial for the following medications for the following dates: Zyprexa Zaydis 5 MG Tablet for 05/31/2024 5:00 PM and 8:00 PM, Keppra 500 MG Tablet for 05/31/2024 5:00 PM, Gabapentin 300 MG Capsule for 05/31/2024. (R3) is missing initial for the following medications for the following dates: Quetiapine 50 MG for 05/31/2024, Oyster shell 500 MG for 05/31/2024 for 2:00 PM and 8:00 PM, Micotine Gum 2 MG for 05/31/2024 6:00 PM, Clobetasol 05/31/2024 6:00 PM, Olanzapine 10 MG for 6:00 PM, and Fenofibrate 160 MG for 05/31/2024. (R4) is missing initial for the following medications for the following dates: Norvasc 10 MG Tablet for 05/31/2024, Vitamin D3 for 05/31/2024, Nizoral 2% Shampoo for 05/31/2024, Lactulose 10 GM for 05/31/2024 8 AM, 2 PM, and 8 PM, Zyprexa 5 MG for 05/31/2024 8 AM and 5 PM, Ditropan XL 10 MG for 05/31/2024. Moreover on 05/31/2024, LPA Lee and direct care staff Theodore Patterson audit (R1)’s medication. During the medication inspection it was learned that there were discrepancies in (R1)'s medications. It was learned that (R1)'s medication for Levetiracetam 500 MG, take 2 tablets by mouth 2 times a day with start date on 03/20/2024 with 180 quantities, as of 05/31/2024 audit (R1)'s Levetiracetam medication had 13 pills remaining in the bottle which (R1) should have had 34 pills left instead. It was also learned that (R1)'s Gabapentin 300 MG take by mouth 2 times a day with a start date of 05/23/2024 is showing that (R1) did not received (R1)'s morning medication for on 05/31/2024.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met.

Allegation: Staff did not assist resident with attending medical appointments and Staff are not properly supervising resident.

It was alleged staff did not assist resident with attending medical appointments and staff are not properly supervising resident. This investigation consisted of record review and interviews with facility staff. LPA Lee reviewed (R1)’s admission agreement on page 2 which states (R1) the facility will assist (R1) in meeting necessary medical and dental needs by arranging and assisting with incidental medical and dental services. Moreover per (R1)’s LIC 602 Physician’s Report (R1) is not able to leave the facility unassisted and that (R1) lacks capacity to make decisions.

Continued LIC 9099-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20240523091818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2024
NARRATIVE
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Record reviewed also revealed that (R1) had an appointment on 05/17/2024 at 1:00 PM with SNAHC Medical. Based on interview with direct care staff Theodore Patterson who admitted that she arranged transportation for (R1) to attend (R1) doctor appointment on 05/17/2024 and no facility staff attended and stay with (R1) during (R1)’s doctor visit. Direct care staff Theodore also stated that she informed the receptionist to call the facility when (R1) is done with (R1)’s appointment.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Kirk Campbell and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20240523091818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/01/2024
Section Cited
CCR
87411(a)
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87411(a) Personnel Requirements - General
Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required…
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Licensee/administrator agrees to conduct Incidental medical and dental training for all facility staff who assist with residents’ medical care and needs. Licensee/administrator will ensure that all residents are assisted with staff
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This requirement was not met as evidence by:

Based on interviews and records review: the licensee did not ensure that a staff assisted (R1) with attending medical appointments and that (R1) was supervised. This posed an immediate health and safety risk to R1.
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attending with residents during all medical appointments. Training materials along with staff sign in signatures will be email to LPA Lee by POC date of 07/05/2024 by 5:00 PM end of day.
Type A
07/01/2024
Section Cited
CCR
87465(a)(4)
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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.
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Licensee/administrator agrees to conduct Incidental medical and dental training for all Med-tech and any staff that handles residents’ medications. Licensee/administrator will email LPA Lee training materials and staff sign in sheet by POC date 07/05/2025.
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This requirement was not met as evidence by:
Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. Based on medication audit it was learned that there were discrepancies in (R1)’s medication. Moreover, 3 out of 4 residents’ MAR logs were incomplete and are missing staff initialed; therefore, it is uncleared if residents received their medications as prescribed. This posed an immediate health and safety risk to residents in care.
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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: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20240523091818
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/24/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/05/2024
Section Cited
CCR
87405(d)
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87405(d) Administrator - Qualifications and Duties
(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply…
This requirement is not meet as evidenced by:
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The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 07/05/2024 by POC date end of day 5:00 PM.
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Based on record review and interview the licensee/administrator did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to residents in care. This posed a potential health and safety risk to residents in care.
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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: 06/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5