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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700921
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:22:30 AM


Document Has Been Signed on 03/08/2023 11:22 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 AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



FACILITY NAME:VITA BELLA ELDERLY CARE IIFACILITY NUMBER:
342700921
ADMINISTRATOR:DIANA GARCIAFACILITY TYPE:
740
ADDRESS:8362 NEW POINT DRTELEPHONE:
(916) 821-4423
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:6CENSUS: 5DATE:
03/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Diana GarciaTIME COMPLETED:
11:30 AM
NARRATIVE
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On 03/08/2023 at 8:20 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with caregiver Marie Taylor then was later joined by administrator Diana Garcia and explained the purpose of the visit. Diana Garcia assisted with today’s visit. Administrator certificate # is 6028860740 and will expired on 07/29/2024.

The facility has one main Covid-19 screening entry point. The facility has Covid-19 posting throughout the facility. The furniture is spaced six feet apart, and the facility does daily cleaning. The facility has a 30-day supply of PPE. LPA Lee inspected the physical plant including but not limited to the common area, kitchen, dining area, client bedrooms, client bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. This facility is a single story building licensed to serve six (6) non-ambulatory residents with a hospice waiver for one residents. LPA Lee observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. 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 124.2 degrees Fahrenheit in resident bathroom sink, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Fire extinguishers, smoke and carbon monoxide detectors are in compliance with fire safety. Fire extinguisher last serviced 06/07/2022. Facility thermostat observed at 71 degrees Fahrenheit. LPA Lee checked medication storage and found medication to be locked away and inaccessible to clients. First aid kit was checked and is complete. LPA requested client and staff files for review. LPA reviewed (3) client files and (3) staff files, including criminal record clearances. A review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. LPA verified staff training for staff file reviews.
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SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
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 3


Document Has Been Signed on 03/08/2023 11:22 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833


FACILITY NAME: VITA BELLA ELDERLY CARE II
FACILITY NUMBER: 342700921

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2023
Section Cited
CCR
87030(e)(2)

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87303(e)(2) Maintenance and Operation
Water supplies and plumbing fixtures shall be maintained as follows...Faucets used by residents for personal care such as shaving, and grooming shall deliver hot water... This requirement was not met as evidence by:
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Administrator Diana Garcia adjust water temperature during todays visit. LPA Lee recheck the water temperature and it measure at 108.0 degrees fahrenheit.


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Based on observation and inspection the licensee did not ensure water temperature measure to the require temperature of 105-120. Resident bathroom sink water temperature measured at 124.2 degrees. This poses a potential health and safety risk to residents in care.
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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: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VITA BELLA ELDERLY CARE II
FACILITY NUMBER: 342700921
VISIT DATE: 03/08/2023
NARRATIVE
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The following documents was provided to LPA Lee during todays visit.
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted, and a copy of the LIC 809, LIC 809-D reports and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3