342700919-8-6-2021-27-AS-THUD-C5N3V7-20210806183439

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 08/06/2021
Date Signed: 08/06/2021 06:37:00 PM

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 CARE		FACILITY NUMBER:	342700919
ADMINISTRATOR:	LABELLA, MARK		FACILITY TYPE:	740
ADDRESS:	4082 73RD STREET		TELEPHONE:	(916) 594-7250
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95820
CAPACITY:	10	CENSUS: 9	DATE:	08/06/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Unaisi Waqalala		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 8-6-21 at 8:45 am Licensing Program Analyst (LPA) Tirzah Hubbard and Licensing Program Manager Stephen Richardson arrived unannounced to conduct a Required Annual 1 Year inspection. LPA and LPM met with Una Waqala Administrator and stated the purpose of today’s visit. LPA and LPM were allowed entry into the facility that is licensed to serve a total capacity of 10 clients. Census: 9 Ratio: 2:9 Fully Vaccinated residents: 5 Partially vaccinated: 4 Fully Vaccinated staff: 3 LPA and LPM interacted with a random number of residents during this visit. Designated Administrator stated, "Staff testing for Covid-19: none Resident testing: none". The physical plant was toured inside and outside to ensure the safety of the residents. LPA and LPM toured the kitchen area, backyard, front yard, bedroom 1, bedroom 2, bedroom 3, and bedroom 4. LPA interviewed a number of residents in the facility. LPA observed when entering the facility 2 Staff present during the visit. LPA observed the physical plant of the facility in moderate condition. LPA observed the flooring of the facility in good condition and hallway flooring in good condition. LPA observed the facility conducts fire drills every 6 months. LPA observed medication not stored and locked away inaccessible to persons in care located on the counter and in cabinets that contained no locks. LPA observed medication not logged into from the dates 8/2/21- 8/6/21 in Medication Administration record (MARS). LPA interviewed S1 to discuss medication storage and MARS daily logs to go over medication procedures. LPA interviewed Residents who indicated they have not received medication for 2-3 days and have not had their medication refilled as requested. R5 Stated, " my leg has been hurting and I am in pain." R1 stated, " I am not feeling well today and the staff has done nothing about it".

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87413(a)(1)

Personnel - Operations

(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation,interview, record review, the licensee did not comply with the section cited above. Adminsitrator indicated there has not been night shift staff for 3 consecutive days. The live in staff are sleep at night and other staff are not on shift which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2021
	Plan of Correction
1 2 3 4	Administrator will hire more staff and schedule more staff.

Type A

Section Cited

CCR

87555(b)(7)

General Food Service Requirements

(b) The following food service requirements shall apply: (7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above. Administrator did not ensure all resdients meal plan needs are met which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2021
	Plan of Correction
1 2 3 4	Administrator will ensure that grocery shopping will be done and resdients meals will modified based on meal plan. Administrator will provide a copy of grocery receipt and a copy of all 9 residents meal plans via email and fax on 8-9-21.

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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: 4 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

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
1 2 3 4	Based on observation,interview,record review, the licensee did not comply with the section cited above in licensee did not ensure non perishable and perishable stored for up to 7 consecutive days which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2021
	Plan of Correction
1 2 3 4	Administrator will show proof of reciept via email for non perishable and perishable foods.

Type A

Section Cited

CCR

87555(b)(27)

General Food Service Requirements

(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in licensee did not ensure that kitchen area and microwave were clean. Kitchen area contained dead flys on counter top which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2021
	Plan of Correction
1 2 3 4	Licensee will clean the facility to get rid of all bugs and clean microwave by 8-9-21.

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700919
	VISIT DATE: 08/06/2021

NARRATIVE

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LPA observed the kitchen area containing dead bugs on the counter and corners. The refrigerator contained food items not properly labeled or packaged. The freezer contained un-packaged and unlabeled meat with freezer burn. LPA observed eggs stored in the cabinet where facility binders are stored. LPA observed no food supplies of staple nonperishable food stored for emergency. There were no perishable foods for a minimum of two days that shall be maintained on the premises at all times. The sharp objects that are : Knives, can openers, scissors locked away.

LPA observed in backyard fence in disrepair, along with old mattresses and bedframes. The backyard contained an old broken dresser. LPA observed window panel next to trash window blinds in disrepair. LPA observed bedroom 1 with broken dresser, bedroom 2 contained broken dresser and bedroom 3 in compliance. LPA observed in bedroom 4 R4 has not been changed since yesterday on 8-5-21 and has been sitting in urine all day. LPA observed medication not distributed to residents for breakfast time.

The temperature inside the facility was measured at 75 *F which is within the required range of 68 degrees F (20 degrees C) and 85 degrees F (30 degrees C), or in areas of extreme heat the maximum shall be 30 degrees F (16.6 degrees C) less than the outside temperature.

The hot water was measured at 105*F which is not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C) as per Title 22 regulations.

The first aid kit was found in compliance containing at least the following: a current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency, sterile first aid dressings, bandages or roller bandages, adhesive tape, scissors, tweezers, thermometers, and Antiseptic solution. LPA Tirzah Hubbard observed a pull alarm system, fire extinguisher(s), smoke and carbon monoxide detectors, central heating and air in the facility. LPA observed the smoke detectors in residents room. LPA observed no smoke detector in dining and kitchen area.

Documents requested during visit: LIC 308, LIC 602, MARS Medication log, LIC500,
Per the California Code of Regulations, Title 22, Division 6, Chapter 8, multiple deficiencies were observed located on 809D. Exit interview held, copy of report given.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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

LIC809 (FAS) - (06/04)

Page: 2 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. The licensee did not ensure all disinfectants were stored and locked away which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2021
	Plan of Correction
1 2 3 4	Administrator locked the disinfectants during the Annual visit on 8-6-21.

Type A

Section Cited

CCR

87309(b)

Storage Space

(b) Medicines shall be stored as specified in Section 87465(c) and separately from other items specified in (a) above. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above. Licensee did not ensure the medication was locked and stored inaccessible to persons in care which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/06/2021
	Plan of Correction
1 2 3 4	Administrator locked the medications away on 8-6-21.

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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: 3 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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 CARE	FACILITY NUMBER: 342700919
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/06/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(28)

General Food Service Requirements

(b) The following food service requirements shall apply: (28) All food shall be protected against contamination. Contaminated food shall be discarded immediately upon discovery. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, record review, the licensee did not comply with the section cited above in the licensee did not ensure all food in freezer were properly labled. LPA observed meat in freezer inproperly packaged and containing freezer burn which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2021
	Plan of Correction
1 2 3 4	Licensee will ensure all food is properly labeled and replaced by date of 8-9-21

Type A

Section Cited

CCR

87616(b)(1)

Exceptions for Health Conditions

(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview,(record review, the licensee did not comply with the section cited above in licensee did not ensure all reports and records for all 9 residents were properly filled out and filed for clients needs which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/09/2021
	Plan of Correction
1 2 3 4	Licensee will send over complete documentation for all 9 residents for care plan, medical records, health prognosis, and expected duration of condition by 8-9-21.

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	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah Hubbard	TELEPHONE: 559-365-5294
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)

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