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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 08/06/2021
Date Signed: 08/06/2021 07:10:54 PM

Document Has Been Signed on 08/06/2021 07:10 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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:
08/06/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
05:30 PM
MET WITH:Una Waqalala TIME COMPLETED:
07:15 PM
NARRATIVE
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On 8-6-21 Licensing Program Analyst (LPA) Tirzah Hubbard and Licensing Program Manager (LPM) Stephen Richardson conducted a case management visit. LPA met with Designated Administrator to discuss the purpose of the visit.

Designated Administrator stated,
" Staff 3 (S3) has been working in the facility for two consecutive months for over night shift with the hours of 7pm to 7am. S3 has called out for the last two days and has worked on 8-2-21 for over night shift."

Based on observation and review of staff personnel records, S3 is not finger print cleared to work in the facility.


The following deficiencies were observed and cited on the following 809D pursuant to title 22 rules and regulations, health and safety code.

Appeal rights were printed and given to facility administrator.

Exit Interview.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2

Created By: Tirzah Hubbard On 08/06/2021 at 04:40 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/06/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/06/2021
Section Cited
CCR
87355(b)

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87355(b)Criminal Record Clearance. (b) Prior to the Department issuing a license, the applicant,administrator and any adults other than client, residing in the facility shall have a criminal record clearance or exemption.

This is not met by evidence by:
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Licensee will ensure all staff is finger print cleared in order to work in the facility. S3 will not work in the facility until cleared to work. Licensee will show proof of finger print clearnace on 8-9-21.
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Based on observation and review licensee did not ensure that all staff have fingerprint clearance in order to work in the facility which poses an immediate health, safety, and personal rights risk for 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.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Tirzah Hubbard
LICENSING EVALUATOR SIGNATURE:
DATE: 08/06/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2021


LIC809 (FAS) - (06/04)
Page: 1 of 1