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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700921
Report Date: 12/16/2021
Date Signed: 12/16/2021 11:46:08 AM

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: DATE:
12/16/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Diana Garcia TIME COMPLETED:
11:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Anthony Tuck arrived at facility unannounced on 12/16/2021 and was met by Staff Diana Garcia. Diana Garcia is the new Administrator. LPA explained the reason for today's visit to conduct a case management visit regarding an incident that occurred on 12/06/2021 involving a resident that resulted in an AWOL.

LPA learned that resident (R1) was discovered by staff (S1) as missing at 4:00 AM on 12/06/2021 during night check rounds. It was learned that staff immediately notified the Administrator (Admin) and emergency dispatch was contacted to report the resident missing. It was learned from that R1 had turned off the alarm on the front door and left unnoticed. LPA learned that that the Admin contacted hospitals and drove around the area to locate R1, however R1 was not found. An additional incident report was received on 12/08/2021 containing updated information on the status of R1. It was learned that the Admin received a call from the Police on 12/07/2021 at 1:00 PM that R1 was found at his friends house in Rio Linda. LPA learned that the Admin picked up R1 and brought R1 back to the care home. LPA reviewed a copy of the LIC 602 form R1, it was learned that R1 is not allowed to leave the facility unassisted and has a diagnosis of Dementia and seizures. It was learned that S1 was on duty the night of the incident. LPA learned from an interview with Administrator that S1 is no longer employed with the facility.

Based upon interviews with Administrator and R1 and review of documentation, per California Code of Regulations, Title 22 Division 6, Chapter 8, A Type B deficiency is being cited today in violation of California Code of Regulations and follows on 809D. Exit interview held with Diana Garcia 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: 12/16/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2021
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: 12/16/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/27/2021
Section Cited

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85078 Responsibility for Providing Care and Supervision
(1) The licensee shall provide those services identified in the client's needs and services plan as necessary to meet the client's needs. This requirement is not met as evidenced by:
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Based on interviews conducted and records reviewed, the licensee did not ensure that R1 was properly supervised resulting in R1 eloping from the facility which posses an immediate health and safety to persons in care
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Licensee/Administrator agrees to submit proof of online training and copy of staff training roster to LPA via email. POC shall be submitted by, 12/27/2021.

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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: 12/16/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2021
LIC809 (FAS) - (06/04)
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