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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 12/01/2021
Date Signed: 05/20/2022 03:16:23 PM


Document Has Been Signed on 05/20/2022 03:16 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: 8DATE:
12/01/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Adminstrator Una WaqalalaTIME COMPLETED:
03:17 PM
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On 12-1-2021 Licensing Program Analyst (LPA) Tirzah Hubbard conducted an unannounced Post-Licensing visit. LPA Hubbard met with Caregiver Kaydia sharp (S1) to discuss the purpose of the visit. LPA Hubbard asked S1 to contact the facility Administrator Una to discuss the purpose of the post-licensing visit. LPA Hubbard was not able to reach Administrator or Licensee to discuss the post-licensing visit.

Administrator Una stated via telephone for call back at 2:00pm that she would be at the facility shortly. LPA Hubbard continued with the post-licensing visit to tour the facility.

LPA Hubbard observed 8 residents at the time of visit. S1 stated the census is 8 at the time with 1 Resident on Hospice. S1 stated there are 3 new residents at this time. Sandra Petmecky (R1) passed away at the beginning of this month, Deborah Fuller (R2) was relocated to another facility, and Mary Clement (R3) is currently hospitalized due to not feeling well from having a stroke. R3 Symptoms were vomiting and diarrhea. R3 tested negative for Covid. Administrator reported incidents via Fax to CCL office. LPA Hubbard will return at a later time to discuss incidents when fax are received. Administrator has agreed to send all incident reports via email to confirm received in office by LPA. LPA Hubbard observed all incident reports during visit but not fax and email.

LPA Toured the physical plant of the facility. LPA observed all residents engaging in activities for the day.
Each staff of the facility are vaccinated. LPA observed all bedrooms containing dresser, night stand, bed, chair, and trash can with lids. LPA observed kitchen in good condition. LPA observed medication stored, organized and locked away. The physical plant was toured inside and outside to ensure the safety of the residents. LPA toured the kitchen area, backyard, front yard, bedroom 1, bedroom 2, bedroom 3, and bedroom 4. LPA interviewed 8 residents in the facility. LPA observed when entering the facility 1 Staff present during the visit. 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.
SUPERVISOR'S NAME: Stephen RichardsonTELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Tirzah HubbardTELEPHONE: 559-365-5294
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2021
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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