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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 02/03/2026
Date Signed: 02/03/2026 11:41:13 AM

Document Has Been Signed on 02/03/2026 11:41 AM - 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: 9DATE:
02/03/2026
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Misivono QadrokaTIME VISIT/
INSPECTION COMPLETED:
11:52 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to conduct a health and safety inspection and a case management visit. The facility is on a quarterly visit due to non-compliance concerns discussed during a Zoom meeting on 11/18/2025. LPAs met with care staff Misivono Qadroka and explained the purpose of the visit. Care staff informed Administrator Aliti Waqalala via text message that Community Care Licensing Division (CCLD) was present at the facility; however, the Administrator did not respond. LPA Lee attempted to contact Administrator Waqalala by phone and left a voicemail. The facility census was nine (9) residents with two (2) staff present.

The purpose of today’s visit was to conduct a quarterly inspection. LPAs followed up on the following areas:

· Incontinence care: LPAs did not observe or detect any incontinence odors throughout the facility.

· Criminal record clearance and staff association requirements: LPAs observed Staff 2 (S2), who is fingerprint-cleared and associated with the facility.

· Fire clearance and fire safety: LPAs observed that the front gate was unlocked and easily operable. Exit doors and emergency exits were observed to allow single-action operation, and residents were not locked in or out of the facility.


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: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2026
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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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: 02/03/2026
NARRATIVE
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· Incidental medical and dental care services: LPAs reviewed Resident 1 (R1)’s Medication Administration Record (MAR) and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. LPAs reviewed R1’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets. A review of the Centrally Stored Medication Destruction Record (CSMDR) showed a start date of 11/05/2025. Care staff Qadroka conducted a pill count and reported ten (10) tablets on hand, indicating discrepancies in R1’s medication count.

· Food supplies: LPAs observed that the facility had sufficient food supplies, meeting the requirements of a two-day perishable and seven-day non-perishable supply at the time of the visit.

· Change in condition assessments and reassessments: LPAs learned that Resident 2 (R2) was sent to the hospital on 10/22/2025 and discharged with a special mechanical-soft diet. A review of R2’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) indicated that the special diet was not updated to reflect this change in condition.

· Door alarms and alert systems: LPAs observed door alarms installed on the front door, dining room sliding door, and the back door of Resident Room #3.

· Quality of food provided: LPAs observed seven (7) residents seated at the dining table eating breakfast. The meal included egg omelets, hash browns, toast, strawberries, blueberries, bananas, and coffee. LPAs also observed apples and oranges available on the kitchen counter for resident access.

· Personal rights: LPAs toured the kitchen and observed that the refrigerator and food cabinets were unlocked, allowing residents access in accordance with personal rights requirements.

· Communication and responsiveness with the Department: LPA Lee emailed Administrator Waqalala on 01/29/2025 requesting additional information and documents related to complaint control number 27-AS-20251231102322, with a due date of 01/30/2025. A follow-up request was also sent on 02/01/2026, with no reply from the Administrator. During today’s visit, care staff Qadroka and LPA Lee were unable to reach Administrator Waqalala.

As a result, of today's quarterly visit, deficiencies can be found on the 809D page. An exit was conducted, and a copy of the 809 report, 809D pages, was provided to care staff Qadroka


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

DATE: 02/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 02/03/2026 11:41 AM - It Cannot Be Edited


Created By: Pang Lee On 02/03/2026 at 11:30 AM
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: 02/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/17/2026
Section Cited
CCR
87465(c)(2)

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87465(c)(2) Incidental Medical and Dental Care
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for non-prescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:
(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
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The facility will conduct Incidental Medical training from CCLD approved venders/Pharmacy regarding resident medication administration and maintaining accurate records of MARs and CSMDR.
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Based on observation, interview and record review, the licensee did not comply with the section cited above. LPAs reviewed Resident 1 (R1)’s Medication Administration Record (MAR) and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. LPAs reviewed R1’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets. A review of the Centrally Stored Medication Destruction Record (CSMDR) showed a start date of 11/05/2025. Care staff Qadroka conducted a pill count and reported ten (10) tablets on hand, indicating discrepancies in R1’s medication count. This poses an immediate health, safety or personal rights risk to people in care.
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 Staff training sign in and documents used for training as well as a statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by 02/17/2026 end of day 5:00 PM
Type B
02/17/2026
Section Cited
CCR87463(a)

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87463(a) Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

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The facility will conduct Reappraisals/change in condition training. Staff training sign-in and documents used for training as well as a statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by
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This requirement is not met as evidenced by:
Based on observation, interview and record review, the licensee did not comply with the section cited above. LPAs learned that Resident 2 (R2) was sent to the hospital on 10/22/2025 and discharged with a special mechanical-soft diet. A review of R2’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) indicated that the special diet was not updated to reflect this change in condition. This poses a potential health, safety or personal rights risk to people in care.
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02/17/2026 at the end of day 5:00 PM. A statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by 02/17/2026 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: 02/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2026


LIC809 (FAS) - (06/04)
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