342700919-8-6-2021-27-AS-KHOS-C6FMYH-20210901100134

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700919
Report Date: 08/06/2021
Date Signed: 08/06/2021 07:03:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/27/2021 and conducted by Evaluator Tirzah Hubbard

COMPLAINT CONTROL NUMBER: 27-AS-20210727104021

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
		UNANNOUNCED	TIME BEGAN:	04:03 PM
MET WITH:	Una Waqalala		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Staff handled resident in a rough manner.

INVESTIGATION FINDINGS:

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On 8-6-21 LPA Tirzah Hubbard and Licensing Program Analyst LPM Stephen Richardson completed an unannounced vist to deliver the findings of complaint investigation. LPA's met with designated Administrator Una Waqalala and provided findings regarding the allegation listed above. The investigation was conducted by LPA TIrzah Hubbard and consisted of reviews of the facility records and interviews with facility management and staff.
The complaint allegation listed above was investigated. The facility staff interviews all confirmed that resident (R-1) made a false statement in regards to staff care. LPAs reviewed records of R-1 Admission agreement. LPA's interview with R-1 concluded the details of the allegation did not occur.

Therefore, this complaint and allegation is determined to be without a reasonable basis and deemed to be UNFOUNDED and is thereby dismissed.

An exit interview was conducted. A copy of the report was provided, a signature on this report acknowledges receipt of documents.

Unfounded

Estimated Days of Completion: 30

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.

LIC9099 (FAS) - (06/04)

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