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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 01/06/2026
Date Signed: 01/06/2026 02:46:54 PM

Document Has Been Signed on 01/06/2026 02:46 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/
DIRECTOR:		ALITI N WAQALALAFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 594-7250
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 10CENSUS: 10DATE:
01/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Misivono QadrokaTIME VISIT/
INSPECTION COMPLETED:
03:05 PM
NARRATIVE
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On 01/06/2026, Licensing Program Analysts (LPAs) Pang Lee and Cynthia Tamayo arrived at the facility to conduct an unannounced annual inspection. LPAs met with Misivono Qadroka and explained the purpose of the visit. LPAs requested that staff notify Administrator Aliti Waqalala of CCLD’s presence. The Administrator’s Certificate number is 7025683740, which expires on 06/16/2027. The facility’s current census is 10 residents, with 2 staff members present. Administrator Waqalala was not present during today’s inspection.

The facility is licensed for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents, with an approved hospice waiver for one (1) resident. LPAs inspected the physical plant, including but not limited to the common areas, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, staff room, and outdoor courtyards, to ensure compliance with Title 22 regulations. LPAs observed the facility to be clean, free of odors, and not in good repair. Resident bedrooms were properly furnished and equipped with appropriate bedding and lighting. During today’s kitchen inspection, LPAs observed insufficient seven-day non-perishable and two-day perishable food supplies. Care staff Qadroka stated that he put in an order for food delivery yesterday and that the delivery should be delivered today around 2:05 PM to 2:35 PM. During the visit, LPAs did observe groceries being delivered to the facility from Walmart. Additionally, during a complaint control Number # 27-AS-20251231102322 on 01/05/2026, LPAs inspected the facility’s food inventory to determine whether adequate food supplies were maintained on the premises, specifically a minimum of two days of perishable food and seven days of non-perishable food, sufficient for ten residents.



CONTINUED LIC 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/06/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 01/06/2026 at 01:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
General Food Service Requirements
(b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. which poses an immediate health, safety or personal rights risk to people in care. LPAs observed insufficient seven-day non-perishable and two-day perishable food supplies. Care staff Misivono Qadroka stated that he put in an order for food delivery yesterday and that the delivery should be delivered today around 2:05 PM to 2:35 PM. Moreover, during a complaint control Number # 27-AS-20251231102322 on 01/05/2026, LPAs inspected the facility’s food inventory and there was also not sufficient food supplies maintained on the premises, specifically a minimum of two days of perishable food and seven days of non-perishable food, sufficient for ten residents.
POC Due Date: 01/07/2026
Plan of Correction
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Facility will provide a written plan of correction on the specific steps the facility will take to ensure the facility maintains an adequate supply of perishable foods to meet the needs of residents. LPA requests copies of all food receipts be sent to LPA Lee @ pang.lee@dss.ca.gov starting 01/06/2026 for the next 6 months (June) every Friday of each week.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 01/06/2026 at 01:38 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(6)
87468.1(a)(6) Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPAs observations the facility gate was manipulated in a way to prevent residents from opening the sliding gate at the driveway and preventing them from leaving the facility. which poses immediate health, safety and personal rights risk to residents in care.
POC Due Date: 01/13/2026
Plan of Correction
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Administrator will provide Inservice training on Personal Rights to include how all staff should close the gate so that it does not manipulate the gate in any way to prevent the residents from leaving the facility. All emergency gate has to be a single action mechanism. A written declaration that no facility staff member will close or manipulate the gate in a way the prevents residents from leaving the facility property and a statement that the regulation being cited has been reviewed and understood by all facility staff. POC due by 01/13/2026 end of day 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/06/2026 02:46 PM - It Cannot Be Edited


Created By: Pang Lee On 01/06/2026 at 01:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above. LPAs observations the facility gate was manipulated in a way to prevent residents from opening the sliding gate at the driveway and preventing them from leaving the facility. which poses immediate health, safety and personal rights risk to residents in care.
POC Due Date: 01/09/2026
Plan of Correction
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Per maintenance Jose Roseindiz the two broken wilndows will be thrown again today. LPAs observed Jose taking the broken windows to be thrown away. Administrator will review the regulation cited and provided a statement of understanding of the citation and proof that the windows have been removed and thrown away.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Pang Lee
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 01/06/2026
NARRATIVE
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LPAs discussed food supply requirements with Administrator Waqalala, who confirmed that the facility did not have sufficient perishable food supplies to prepare 60 meals for ten residents, nor sufficient non-perishable food supplies to prepare 210 meals. LPA Tamayo observed one resident request seconds; however, no additional breakfast food was available. Staff member S3 offered the residents an apple retrieved from the microwave. S3 stated that the fruit basket was placed in the microwave overnight to clear the counters and to prevent residents from eating fruit at night. S3 agreed to place the fruit basket on the kitchen counter so it would be accessible to residents. Moreover, on 01/05/2026 during a complaint control investigation, LPAs also observed the front gate to be manipulated in a way that prevents residents from easily opening the perimeter gate and exiting the facility grounds.

Hot water temperature measured 112.8 degrees Fahrenheit at a resident bathroom sink, which is not within the required range of 105 to 120 degrees Fahrenheit. Smoke detectors and carbon monoxide detectors were observed to be in compliance with fire safety requirements. A fire extinguisher was observed in the kitchen and was last serviced on 01/22/2025. LPAs reminded the facility that the fire extinguisher is due for servicing this month. The last fire drill was conducted on 10/27/2025. LPAs observed a working public telephone located in the kitchen and verified that required postings were displayed. The facility thermostat was observed at 76 degrees Fahrenheit, which is within the required range of 68 to 85 degrees Fahrenheit. LPAs observed toxic substances stored in the kitchen cabinet and kept locked and inaccessible to residents. Sharp knives were observed to be locked in a kitchen cabinet and inaccessible to residents. Medications were observed to be properly stored, locked, and inaccessible to residents; however, during the first aid kit inspection LPAs observed a bottle of over-the-counter pain medication inside the first aid kit made accessible to residents since the first aid kit was not locked. Care staff Qadroka removed the medication and locked it up. The first aid kit was inspected and contained all required components. LPAs observed two broken windows in the courtyard. During a case management on 09/30/2025, LPA Tamayo provided the facility with a Technical Violation requesting that the broken windows be discarded by 10/07/2025; however, the windows have not been removed as it is a safety hazard. During the visit, LPAs observed maintenance Roseindiz taking the broken windows to be thrown away.

CONTINUED LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
Page: 6 of 8
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
VISIT DATE: 01/06/2026
NARRATIVE
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LPAs reviewed medications for 3 of 10 residents by comparing medications on hand with the Medication Administration Records (MARs) and observed discrepancies. It was observed that MARs were not initialed for multiple days, making it unclear whether medications were administered as prescribed or whether staff didn’t initial the MARs. Additionally, medications were observed not to be administered in accordance with the bubble pack instructions for days and times for residents. Citations will be issued on complaint control Number # 27-AS-20251231102322. LPAs reviewed 5 of 10 resident files, which were complete. LPAs also reviewed 3 staff files, which were complete. A review of staff criminal record clearances confirmed that all facility staff and required individuals are fingerprint-cleared and associated with the facility.

The following documents are to be emailed to LPA Lee by 01/09/2026 by 5:00 PM:

1. LIC 308 – Designation of Administrative Responsibility

2. Copy of Administrator Certificate

3. LIC 610 – Current Emergency Disaster Plan

4. Proof of Current Liability Insurance

5. LIC 500 – Current Personnel Report

LPAs reminded the facility that their annual fees are due and that LPA Lee will email Administrator Waqalala the PIN number, which can be used to pay the balance at CCLD website http://www.ccld.ca.gov/.

As a result of this annual visit, the facility is not in compliance with Title 22 regulations. Deficiencies are documented on LIC 809-D. An exit interview was conducted with Care staff Qadroka, and copies of LIC 809, LIC 809-D, and appeal rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Pang Lee
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/06/2026
LIC809 (FAS) - (06/04)
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