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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 09/30/2025
Date Signed: 09/30/2025 05:17:09 PM

Document Has Been Signed on 09/30/2025 05:17 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:
09/30/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:02 PM
MET WITH:Merelisoni MataitogaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to follow up on a case management deficiency from a previous complaint visit and quarterly visit, and POC follow up. LPA's identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA's requested to speak with Licensee and S4 contacted them. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) and explained the purpose of this visit.

The purpose of this visit was to conduct a quarterly visit to follow up on items outlined during the Non-compliance meeting held on 01/30/2025, which included the requirement for increased monitoring and to follow-up on areas of concern originally identified during the meeting as below.

· Basic Services (care/supervision/elopement)


· Administrator qualifications/duties and accountability/new potential administrator
· Reporting requirements
· Incidental Medical and Dental Care Services (resident not receiving medication as prescribed)
· Fire clearance (adhering to fire clearance/submitted facility sketch)
· Limitations capacity and ambulatory status (non-ambulatory resident cannot reside in an ambulatory room)

· Plan of corrections (POCs) submitted in a timely manner

Continued on 809-C

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2025
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 09/30/2025 05:17 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 09/30/2025 at 02:08 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: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
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Facility staff will conduct daily audits of the centrally stored medications and MAR for the next days and weekly audits thereafter for 30 days with proof of audit logs submitted to Licensing once after the initial days and again after 30 days. Facility to submit an audit plan to Licensing via email by 10/7/2025 at 5:00 pm PST.
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 Based on observation and records review the licensee/admin did not comply with the section cited above. 1 of 1 residents on 8/31/2025 and for 10 of 10 of the resident's medications in the Medication Administration Records from 9/1/2025- 9/4/2025 were not recorded and given per physician's orders according the facility's Plan of Operation which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
10/10/2025
Section Cited
CCR87468.1

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87468.1 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: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.

(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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Facility will submit agreement to not lock food from residents in compliance with regulation 87468 by POC due date. Facility will remove lock mechanism from food storage areas such as the pantry
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Based on observation and records review the licensee/admin did not comply with the section cited above in which the pantry closet has a locking mechanism which poses an immediate health, safety or personal rights risk to persons 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/30/2025 05:17 PM - It Cannot Be Edited


Created By: Cynthia Tamayo On 09/30/2025 at 03:40 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: 09/30/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/10/2025
Section Cited
CCR
87625(b)(3)

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87625(b)(3) Managed Incontinence
(b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility
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Administrator agrees to conduct training on managed incontinent care protocols, emphasizing the importance of timely changing of incontinence products and maintaining cleanliness to prevent odors. Training materials used and staff sign in sheets along with statement of acknowledgement of understanding the regulation cited will be provided to LPAs by POC date 10/10/2025.

As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
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remains free of odors from incontinence.
This requirement is not met as evidenced by: In resident bedroom #2, LPAs observed that the room was unoccupied and had a noticeable incontinence odor. On resident bed B, LPAs observed that an incontinence pad with visible urine had not been disposed of. According to Staff #1, the room had not been cleaned all day, as they believed it was locked. which poses an immediate health, safety, or personal rights risk to persons 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.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Cynthia Tamayo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/30/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2025


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: 09/30/2025
NARRATIVE
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· Background/fingerprint clearance (volunteers)
This visit is also to follow-up on POC that was due to the department on 09/24/2025. This facility is licensed as a Residential Care Facility for the Elderly and is approved to serve a maximum of 10 residents. This facility is approved for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents. During the visit, LPAs conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms, bathrooms, laundry room, and outdoor courtyards. The facility was observed to be clean and in good repair and not free of odor. LPAs observed that the previously broken windows had been repaired and were in good condition. The exit gate was also observed to be functioning properly, with a one-way mechanism that does not prevent residents from exiting the facility. In resident bedroom #2, LPAs observed that the room was unoccupied and had a noticeable incontinence odor. On resident bed B, LPAs observed that an incontinence pad with visible urine had not been disposed of. According to Staff #1, the room had not been cleaned all day, as they believed it was locked. All residents bedrooms were properly furnished with appropriate bedding and adequate lighting. The layout of the facility was consistent with the original facility sketch that had been approved during the licensure process. In the resident bathroom, the hot water temperature was measured at 105.8 degrees Fahrenheit, which falls within the required regulatory range of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors were tested and found to be functioning and in compliance with fire safety regulations. The fire extinguisher was located in the kitchen and had last been serviced on 01/22/2025. LPA also observed that the facility had a public telephone located in the common area. The thermostat was functioning properly and registered at 69 degrees Fahrenheit at the time of inspection. Toxic cleaning supplies were observed to be stored in storage cabinet and securely locked and inaccessible to residents. Sharp kitchen knives were locked in kitchen cabinets and were not accessible to residents.
The medication storage area was reviewed and found to be locked and secure. All records reviewed were found to be complete and accurate. The first aid kit was checked and contained all required supplies. LPAs also verified the food supply, confirming that the facility maintained at least a two day supply of perishable food items and a seven-day supply of nonperishable items, in accordance with Title 22 regulations. LPAs observed a new freezer was placed in the kitchen to store additional food. Both residents’ and staff files were reviewed during the visit and were found to contain all required documentation. It is noted that on January 30, 2025, during a non-compliance meeting, the Licensee, Mark Labella, declined the referral to participate in the Technical Support Program (TSP). Despite the program being recommended as a resource to support compliance, the Licensee refused the referral at that time. The recommendation for TSP participation was reiterated; however, the Licensee again declined to participate.
Continued 809-C
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
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: 09/30/2025
NARRATIVE
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During today’s visit, LPAs also followed up on the prior deficiencies and plan of corrections that were due on 09/24/2025 from a prior case management visit conducted on 09/23/2025.

Based upon this inspection, LPAs observed the following:
1. The deficiency cited under Title 22 Regulation 87303(a) has been cleared. The license did comply with the terms of the POC-by-POC due date. A POC letter was generated and provided to the licensee.

2. The deficiency cited under Title 22 Regulation 87555(b)(26) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.

3. The deficiency cited under Title 22 Regulation 87468.1(a)(6) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.

The following deficiencies were observe by LPA Tamayo:
On 8/28/25, 9/4/25, and 9/8/25 food items in the pantry were locked with a magnetic lock, staff immediately unlocked on 9/8/2025. On 9/30/25, the lock mechanism was not activated but has not been installed. On 8/28/25, 9/4/25, and 9/8/25, eggs were stored in the pantry area however they should be refrigerated as indicated in the box. Staff immediately disposed on eggs and placed an order for fresh eggs.

On 9/4/25, LPA Tamayo observed the MARS was not completed from 8/31/25-9/4/25. staff and resident interviewees confirm medications were given, however not documented accordingly.

LPA's talked to staff regrading disposing of spare windows and broken chairs in the backyard area.

As a result of this case management visit the facility is not in full compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.
NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Cynthia Tamayo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 09/30/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025
LIC809 (FAS) - (06/04)
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