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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700921
Report Date: 11/10/2021
Date Signed: 11/16/2021 01:28:05 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: 5DATE:
11/10/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Bianca CastroTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility unannounced to conduct a case management visit on 11/10/2021. LPA met with back up Administrator Bianca Castro and explained the purpose of the visit.

The purpose of the case management visit is to follow up on a learned deficiency during a complaint investigation.

It was learned the facility did not provide an (LIC 624) unusual incident report regarding the behavioral changes of a resident to Community Care Licensing within the required 7 days of the occurrence.

As a result, the facility is not adhering to Title 22 Regulations, and the deficiency can be found on the 809-D report. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Bianca Castro. Copy of the report was left with the facility upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2021
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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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 II
FACILITY NUMBER: 342700921
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/15/2021
Section Cited

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87211 Each licensee... furnish... licensing... reports... including, but not limited to...written report shall be submitted to... licensing agency and to the person responsible for the resident... seven days of... occurrence... This requirement was not met as evidenced by:
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Based on interviews and documentation received the licensee did not ensure that reporting requirements were met. This poses a potential risk to persons in care.
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Licensee shall submit proof of online traiining certificate and proof of all staff attendance for training completed to LPA by POC due date: 11/15/2021 via email.

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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) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:
DATE: 11/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/10/2021
LIC809 (FAS) - (06/04)
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