342700919-8-12-2024-27-AS-KHOS-D8BKEE-20240820075014

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700919
Report Date: 08/12/2024
Date Signed: 08/12/2024 12:28:23 PM

Unsubstantiated

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
06/11/2024 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20240611111254

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: 8	DATE:	08/12/2024
		UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Adi Lina Tuiloma and Aliti Waqalala		TIME COMPLETED:	10:45 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident sustained unexplained injury while in care.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/12/2024 at 10:10 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Adi Lina Tuiloma and Aliti Waqalala and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 8 with 2 facility staff. LPA Lee called administrator Mark Labella and left a message. A brief interview was conducted with designated staff Theodore Slypher via telephone. During today’s visit administrator Mark Labella was not present.

Allegation: Resident sustained unexplained injury while in care.
It was alleged that resident sustained unexplained injury while in care. This investigation consisted of records reviewed, interviews with staff, residents and an outside agency. Throughout the course of the investigation, it was learned that resident 1 (R1) was admitted to the facility on 05/31/2024 with existing rash condition on (R1)’s back.
Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 27-AS-20240611111254

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: 08/12/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

On 06/02/2024 (S1) took photos of (R1)’s back and had concerned and sent those pictures to the Licensee/Administrator. It was also learned that (R1) came to the facility with home health nurse. LPA Lee reviewed (R1)’s Care Daily Checklist and it was documented that (R1) had bruises on (R1)’s back shoulder and waist from 06/01/2024 to 06/02/2024. It was also documented on 06/03/2024 to 06/06/2024 that (R1) has blister on (R1)’s back shoulder and waist. (S1) stated that (R1) came to the facility with bruise like rashes and denied the allegation. LPA Lee also interviewed 8 out of 8 residents who have no concern with their care from facility staff and denied any abuse from facility staff. LPA Lee interviewed (R1) who also denied the allegation of any injury and any abuse from the facility staff. LPA Lee also interviewed (R1)’s home health nurse who stated that (R1) has had the rash condition prior to coming to Vita Bella Elderly Care and that they have prescribe (R1) with anti-fungal cream. Home health nurse also stated that he/she has no concerns with the care and stated that (R1) is doing a lot better at Vita Bella Elderly Care. LPA was unable to corroborate the allegation that resident sustained unexplained injury while in care.

Based on information and interview gathered there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore, the allegation is found to be unsubstantiated. An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 2