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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 09/17/2024
Date Signed: 09/17/2024 01:33:15 PM


Document Has Been Signed on 09/17/2024 01:33 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: 9DATE:
09/17/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Nina TuilomaTIME COMPLETED:
11:35 AM
NARRATIVE
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On 09/17/24 at 9:57 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a case management visit regarding an Absent Without Leave (AWOL) incident which occurred on 09/14/2024. LPA Lee met with care staff Nina Tuiloma who then called the designated staff, Diana Garcia to informed that Community Care Licensing Department (CCLD) is present in the facility. LPA Lee explained the purpose of the visit. The census is 9 with 2 facility staff.

At 10:33 AM, LPA Lee toured the facility with care staff Nina, to ensure the safety of the residents. During the tour it was observed that the front door alarm is not in good repair. It is unclear if the alarm is broken or needing a new battery. LPA interviewed designated staff Diana and reviewed incident report dated 09/14/2024. Based on interview and record review, LPA Lee was informed that R1 switched off the front door alarm and left the facility unsupervised. Moreover, the administrator received a call from the resident’s family member informing that (R1) had been found and taken to Kaiser South. Based on (R1)'s LIC 602, Physician Report dated 09/12/2024 (R1) is unable to leave the facility without supervision. It was also learned that the facility staff was not aware that (R1) had left the facility until the family called and informed the administrator that the residents is at the hospital.

Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $1000 is issued in addition to citation due to absence of supervision. An exit interview was conducted with care staff Nina. A copy of this report LIC 809, LIC 809-D, LIC 421 IM and appeal rights was provided to care staff Nina at the end of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 09/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
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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Document Has Been Signed on 09/17/2024 01:33 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: 09/17/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2024
Section Cited
CCR
1569.312(a)

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1569.312(a) 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 is not met as evidenced by:
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The facility shall conduct an in-service training on basic services with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training with materials used for the training on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended.
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Based on interviews and records review, the facility did not comply with section cited above when (R1) AWOL'D from facility. The LIC 602 states the resident is not allowed to leave the facility unassisted. This posed an immediate health and safety risk to the resident in care.
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A statement of correction and acknowledgement of the regulation cited and will also be complete and submit to LPA Lee. The Administrator shall email the date of the in-service training, materials used to train staff, plans to ensure resident do not AWOL and statement of acknowledgement to LPA by POC date 09/23/2024 end of day 5:00 PM


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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: 09/17/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/17/2024
LIC809 (FAS) - (06/04)
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