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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 12:36:29 PM


Document Has Been Signed on 08/12/2024 12:36 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:POCUNANNOUNCEDTIME BEGAN:
11:52 AM
MET WITH:Adi Lina Tuiloma and Aliti WaqalalaTIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 08/12/2024 at 11:52 AM to conduct an unannounced Plan of Correction (POC) visit. LPA met with care giver Adi Lina Tuiloma and Aliti Waqalala and explained the purpose of the visit. The purpose of this visit is to verify the plan of correction that was required to be completed on 07/01/2024 and 07/05/2024 for deficiencies that were previously cited on a prior visit conducted on 06/24/2024. During today's 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.

Based upon this inspection, LPAs observed the following:

I. The deficiency cited under Title 22 Regulation 87411(a) has not been cleared. The license did not comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.

II. The deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did not comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.

III. The deficiency cited under Title 22 Regulation 87405(d) has not been cleared. The license did not comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.



As a result of this, POC visit the facility is not in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809, LIC 809D reports and appeal rights were provided 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 3


Document Has Been Signed on 08/12/2024 12:36 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
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…

This requirement was not met as evidence by:
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Administrator agrees to conduct Personnel Requirements training for all facility staff who assist with residents with residents’ necessary services to meet resident’s needs. Administrator will email LPA Lee training documents used for training.
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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. This posed an immediate health and safety risk to R1.
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Administrator will also email LPA Lee staff sign in sheet to reflect staff who received the training. POC due by 08/16/2024 by end of day 5:00 PM.
Type A
08/16/2024
Section Cited
CCR87465(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.

This requirement was not met as evidence by:
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Administrator agrees to conduct Incidental medical and dental training for staff that handles residents’ medications. Administrator will email LPA Lee training materials and staff sign in sheet by POC date 08/16/2024 by end of day 5:00 PM.
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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: 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 3


Document Has Been Signed on 08/12/2024 12:36 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 B
08/16/2024
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 08/16/2024 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: 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: 3 of 3