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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 04/14/2021
Date Signed: 04/15/2021 11:25:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME:VITA BELLA ELDERLY CAREFACILITY NUMBER:
342700919
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 821-4423
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY:10CENSUS: 4DATE:
04/14/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:35 PM
MET WITH:Mark LabellaTIME COMPLETED:
04:30 PM
NARRATIVE
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Due to computer issues this Case Management will be completed today 4-15-21. Administrator agreed.

Licensing Program Analyst (s) (LPA) Tirzah Hubbard and Victoria Brown contacted the facility via telephone to conduct a Case Management visit on 4/14/21 at 4:00pm due to COVID-19 and pre-cautionary measures. LPA’s met with Mark Labella to discuss elements of this type of visit and purpose of the call.

LPA’s Interviewed the administrator during this visit regarding a Community Care Licensing (CCL) visit on 4-13-21. CCL staff witnessed the facility did not screen visitors. In addition, staff and residents were not wearing masks. CCL staff also observed hand sanitizer and sign in sheet at the front door.

LPA reviewed the facility Mitigation plan that was received on 3-12-21 and returned on 3-17-21. The revised mitigation plan has been received and needs more revision. It shall be submitted in 1 week.

The preponderance of evidence standards has not been met.


Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 8, the following deficiencies are being cited on the attached 809D during this visit. If any of the cited deficiencies are not corrected by the noted due dates; civil penalties may be assessed. The Administrator was provided a copy of their rights (LIC9058) and their signature on this form acknowledges receipt of these rights.



An exit interview was conducted with Mark Labella via telephone and a copy of this report was provided via email and an electronic email read receipts confirms receiving these documents.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/14/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/16/2021
Section Cited

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Personal Rights
(d) The following space and safety provisions shall apply to all facilities:
(3) All persons shall be protected against hazards within the facility through provision of the following:
(B) Information and instruction regarding life protection and other appropriate subjects.
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This requirement is not met as evidenced by: During a facility visit by CCL, Staff observed staff and residents not wearing mask and screening not being conducted. Based on observations licensee did not ensure visitors screening was conducted and that staff or residents were wearing mask as stated in PIN 20-46-ASC.
This violation poses an immediate health, and safety risk to residents in care.

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Licensee shall submit a plan of how these guidelines will be followed by POC due date of 4-16-21.
In addition, licensee shall submit a copy of the screening log for the next two weeks via fax 05-1-21.


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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: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 916-263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2021
LIC809 (FAS) - (06/04)
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