342700921-12-9-2021-27-AS-CACL-C9RP2V-20211216095634

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700921
Report Date: 11/10/2021
Date Signed: 12/09/2021 11:01:10 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20210907115135

FACILITY NAME:	VITA BELLA ELDERLY CARE II		FACILITY NUMBER:	342700921
ADMINISTRATOR:	LABELLA, MARK		FACILITY TYPE:	740
ADDRESS:	8362 NEW POINT DR		TELEPHONE:	(916) 821-4423
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 5	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff Jacqueline Rose Dwyer		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Staff did not assist resident with medication as needed.
Resident was not accorded dignity in personal relationships with staff.
Facility is in disrepair.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 27-AS-20210907115135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/10/2021

NARRATIVE

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LPA reviewed copies of documents received for R6, LPA reviewed interview notes held with residents and staff conducted on prior visit date 09/15/2021. LPA reviewed phone interview notes conducted on 10/19/2021 with Administrator. LPA inspected 3-bathroom showers at the facility on initial investigation date 09/15/2021. LPA conducted interviews with the administrator 3 out of 6 staff and 4 out of 5 residents. S4 and S5 never returned phone calls from LPA placed on 10/19/2021. LPA reviewed interview notes from Admin, S1, S2 and S3. LPA reviewed interview notes from R1, R2, R3 and R4. LPA reviewed copy of SIR for R6 regarding a reported fall in the bathroom dated 08/05/2021. LPA reviewed copies of daily care notes for R6, LPA reviewed copy of LIC 602 for R6, LPA reviewed copy of MAR for R6 for month of August. LPA inspected bathrooms at facility and observed that none of the showers have safety bars inside the showers that were reported as being broken. LPA reviewed copy of appraisal needs service plan for R6.
Continued on LIC 9099C...
LPA interviewed POA for R6. POA could not provide dates for when alleged falls occurred. LPA learned W1 who is the cousin of POA frequently visited R6. LPA attempted to contact W1 by telephone but never received a call back. LPA reviewed copy of text message transcripts between S3 and POA, LPA learned that the POA did not provide S3 with all of the prescription changes for R6. LPA was not able to establish a timeline for when alleged falls occurred. LPA learned that S1 started working at the facility as of 08/20/2021 and the prior staff who was working with R6 is no longer employed by the care home and did not return any phone calls to LPA.
Based upon interviews conducted and documentation reviewed LPA is not able to substantiate findings for the following complaint allegations. 1) Staff did not assist resident with medication as needed. LPA found no missed medications on copy of MAR for R6. 2) Resident was not accorded dignity in personal relationships with staff. Based on interviews with staff and residents, LPA could not determine resident was mistreated. 3) Facility is in disrepair. LPA did not find showers having broken safety bars. There is not substantial evidence to support or disprove that the alleged violations occurred. Due to the preponderance of evidence standard not being met by the department standard. There is no physical evidence to support the validity of the allegations as well as witness statements; LPA has deemed the complaint findings as UNSUBSTANTIATED. Although the allegations may have happened and/or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted with back up administrator Diana Garcia. A copy of this report was left with the facility upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2021 and conducted by Evaluator Anthony Tuck

COMPLAINT CONTROL NUMBER: 27-AS-20210907115135

FACILITY NAME:	VITA BELLA ELDERLY CARE II		FACILITY NUMBER:	342700921
ADMINISTRATOR:	LABELLA, MARK		FACILITY TYPE:	740
ADDRESS:	8362 NEW POINT DR		TELEPHONE:	(916) 821-4423
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 5	DATE:	11/10/2021
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Staff Jacqueline Rose Dwyer		TIME COMPLETED:	04:50 PM

ALLEGATION(S):

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Licensee did not ensure regular observation of resident for changes in physical, mental and emotional functioning.

INVESTIGATION FINDINGS:

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LPA Anthony Tuck conducted an unannounced visit to the facility location on 11/10/2021 at 10:00 AM. LPA was met by care staff Jacqueline Rose Dwyer. LPA explained the purpose of today's visit to continue the investigation of the complaint allegations listed above and conclude the complaint investigation.

LPA reviewed copies of documents received for R6, LPA reviewed interview notes held with residents and staff conducted on prior visit date 09/15/2021. LPA reviewed phone interview notes conducted on 10/19/2021 with Administrator. LPA learned that although the Administrator spoke with R6 regarding his behaviors towards staff, LPA learned that the Administrator did not document behavior changes for R6. LPA learned that although the Assistant Administrator did report behavior changes to the POA of R6, LPA learned that there was no documentation that the POA was contacted. LPA learned that although the Physician was contacted regarding R6's behaviors towards staff, the Administrator did not document that the physician was contacted.
continued on LIC 9099...

Substantiated

Estimated Days of Completion: 90

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 27-AS-20210907115135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/10/2021

NARRATIVE

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The preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The following deficiency was observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. Exit interview was conducted with Back up Administrator Bianca Castro. Copy of the report was left with the facility upon exit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 27-AS-20210907115135

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee... ensure... observed... changes in physical, mental, emotional and social functioning... licensee... ensure... changes are documented... brought to... attention of... resident's physician... resident's responsible person... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	The Licensee agrees to document all observations of residents in care and report any changes in physical, mental, emotional and social functioning to responsible parties, and physicians of presons in care.
	8 9 10 11 12 13 14	Based upon interviews, telephone calls and documents received. The licensee failed to document records of conversations discussed with responsible party and physician of resident. This poses a potential risk to persons in care.	8 9 10 11 12 13 14	Licensee shall provide additional training to all staff on reporting behavior changes of residents. Licensee agrees to submit proof of training provided to LPA via email by POC due date 11/15/2021.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony Tuck	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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