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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 10/07/2025
Date Signed: 10/07/2025 01:03:06 PM

Document Has Been Signed on 10/07/2025 01:03 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:
10/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:23 AM
MET WITH:Aliti WaqalalaTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/07/2025 to conduct a case management visit. LPA Lee met with Administrator Aliti Waqalala and explained the purpose of the visit. LPA Lee spoke with administrator Waqalala regarding the purpose of today’s visit and the deficiencies observed on 10/07/2025.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation control number # 27-AS-20251002101620. Upon arrival, LPA Lee rang the doorbell and observed through the glass window that care staff (S1) attempted to open the door but was unsuccessful. A few seconds later, S1 unlocked the door with a key and allowed LPA Lee to enter. LPA Lee questioned S1 why the front door is locked and S1 explained that the front door is locked at night and had not yet been unlocked for the morning. Based on observation, the facility’s front door is equipped with a reverse lock, which means that when it is locked from the inside with a key, the door cannot be opened to exit the building. During the visit, Administrator Aliti Waqalala was present in the kitchen preparing breakfast for the residents. In an interview, Administrator Waqalala stated that she locks only the front door every night at approximately at 8:00 PM due to a few residents specifically resident 1 and resident 2 (R1 and R2) who leave the facility and wander at night. LPA Lee inquired about why R1 is not allowed to leave independently, especially if R1’s LIC 602 Physician’s Report indicates R1 may leave unassisted. Administrator Waqalala responded that although R1 may be permitted to leave, allowing R1 to do so then R2 also wants to leave the facility as well which could create safety concerns. Additionally, during the visit, a grocery delivery from Walmart was received.

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: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2025
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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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: 10/07/2025
NARRATIVE
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Based on observations and interviews the administrator did not comply with Fire Safety and residents' personal rights requirements by locking the emergency front door at night, which violates California Code of Regulations Section 87203 Fire Safety and 87468.1(a)(6) Personal Rights of Residents in All Facilities

The following deficiencies were identified and cited in accordance with the California Code of Regulations, Title 22, and the California Health and Safety Code. Additionally, an immediate civil penalty of $500.00 was accessed on 10/07/2025 and a repeat violation in the amount of $1000 since this violation was also cited on 09/23/2025. The deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, LIC 421IMs and appeal rights were given to the facility.

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

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/07/2025 01:03 PM - It Cannot Be Edited


Created By: Pang Lee On 10/07/2025 at 12:24 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: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/08/2025
Section Cited
CCR
87203

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87203 Fire Safety
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
This requirement is not met as evidenced by:

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Administrator agrees to not lock the door from inside the facility and will reverse the lock to ensure that facility can’t lock from inside the facility. Administrator will also review the regulation cited today
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Based on observations and interviews, it was learned that the administrator did not comply with Fire Safety requirements by locking the emergency front door at night. This posed an immediate health and safety risk to residents in care.

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and provide LPA Lee a statement of acknowledgement of understanding the regulation. Administrator will provide LPA Lee photos of the lock being revised. POC due 10/08/2025 end of day 5:00 PM

Type A
10/08/2025
Section Cited
CCR87468.1(a)(6)

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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 requirement is not met as evidenced by:
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 Administrator agrees to not lock the door from inside the facility and will reverse the lock to ensure that residents who are allowed to leave the premises based on their LIC 602 Physician’s report they are able to leave.
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Based on observations and interviews the administrator did not comply with residents’ personal rights by locking the front door with a key at night so that residents can’t leave the premises.

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 Administrator will also review the regulation cited today and provide LPA Lee with a statement of acknowledgement of understanding the regulation. Administrator will provide LPA Lee photos of the lock being revised. POC due 10/08/2025 end of day 5:00 PM
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: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2025


LIC809 (FAS) - (06/04)
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