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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:30:11 PM


Document Has Been Signed on 08/12/2024 12:30 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:
08/12/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Adi Lina Tuiloma and Aliti WaqalalaTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 08/12/2024 at 10:45 AM to conduct a case management visit. LPA Lee met with care giver Adi Lina Tuiloma and Aliti Waqalala and explained the purpose of the visit. LPA Lee called administrator Mark Labella and left a message. Administrator was not present during today’s visit. The current census is 8 with two facility staff.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation control number # 27-AS-20240523091818. Throughout the complaint investigation, it was learned that resident 1 (R1) had an appointment on 05/17/2024 at 1:00 PM with SNAHC Medical. Based on interview with designated facility staff (S1) who admitted that (S1) did arranged transportation for (R1) to attend (R1)'s doctor appointment on 05/17/2024 and that no facility staff attended and stay with (R1) during (R1)’s doctor visit. (S1) also stated that (S1) informed the receptionist to call the facility when (R1) is done with (R1)’s appointment. (S1) admitted that (S1) didn’t supervised (R1) during (R1)’s doctor appointment because (S1) also had another appointment for herself/himself. Based on (R1)’s admission agreement on page 2 which states 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 states that (R1) is not able to leave the facility unassisted and that (R1) lacks capacity to make decisions.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeal rights were given 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: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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 2


Document Has Been Signed on 08/12/2024 12:30 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: 08/12/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/16/2024
Section Cited
HSC
1569.312(a)

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§1569.312 Basic services requirements
Every facility required to be licensed under this chapter shall provide at least the following basic services:
(a) Care and supervision as defined in Section 1569.2.
This requirement was not met as evidence by:
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Licensee/administrator agrees to conduct Basic Service training for all facility staff. Licensee will submit to LPA Lee documents used for training and a sign in sheet to show staff train. Licensee will ensure that all residents are supervised at all times. POC is due by 08/16/2024 by 5:00 PM end of day.
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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. (R1) was drop off unsupervised at (R1)'s doctor's appointment. This posed an immediate health and safety risk to R1.
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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: 08/12/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2