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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700921
Report Date: 08/31/2021
Date Signed: 08/31/2021 12:01:26 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 IIFACILITY NUMBER:
342700921
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:8362 NEW POINT DRTELEPHONE:
(916) 821-4423
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 6DATE:
08/31/2021
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Mark LabellaTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Anthony Tuck Island arrived to conduct an unannounced Post licensing inspection on 08/31/2021. LPA met with Mark Labella and explained the purpose of the visit. Mark Labella is the Administrator and holds certificate #6028860740 that expires on 07/29/2021.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and has a hospice waiver for 1 resident. LPA toured the physical plant including but not limited to two resident bedrooms, two resident bathrooms, garage and backyard area. LPA observed the facility to be free of odor, clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. There are no bodies of water present.

LPA observed sufficient seven day non-perishable and two day perishable food supplies. Hot water temperature was measured at 120 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers and smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 05/19/2021. Thermostat observed at (74) degrees Fahrenheit. LPA observed centrally stored medications, toxins and sharp knives kept locked and inaccessible to clients. LPA reviewed resident roster. LPA reviewed staff associations to the facility. First aid kit was checked and is complete.

The following forms were requested during today's visit on 08/31/2021:
LIC 308 LIC 9020
LIC 500 copy of Admin Certificate
LIC 610 copy of liability insurance
Per California Code of Regulations, Title 22 Division 6, Chapter 8, No deficiencies were cited during today's visit. Exit interview held with Mark Labella and a copy of report given at the conclusion of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
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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