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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342700921
Report Date: 12/22/2021
Date Signed: 12/22/2021 03:43:32 PM



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
09/23/2021 and conducted by Evaluator Anthony Tuck
COMPLAINT CONTROL NUMBER: 27-AS-20210923104333
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:
12/22/2021
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Administrator Diana GarciaTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Resident is not being provided medication as prescribed
Resident is not being properly turned while in care
Resident was left soiled multiple times while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Anthony Tuck arrived at the facility unannounced and was met by title Administrator Diana Garcia on 12/22/2021. LPA explained the purpose of today's visit to conclude the complaint investigation and review findings for the allegations listed above.
LPA conducted interviews with R1 on 09/30/2021 and R2 on 12/17/2021. LPA requested and received copies of facility documents for R1. LPA requested and received copies of medical history for R1 from Dignity Health ROI Department. LPA conducted an interview with S2 and learned that S2 was not aware of any issues with R1 regarding being properly cared for by S1. LPA learned from an interview with R2 that S1 was only rotating R1 4 times per day. LPA learned from review of client care daily checklist for R1, that R1 was not being rotated regularly upon first day of admission on 07/13/2021 to the date of 09/29/2021. It was noted that S1 did not start rotating R1 every 2 hours until being told to do so by wound care nurse on 09/29/2021. LPA learned from review of MAR for R1 that not all medications were logged as being given to R1 by S1 on 09/22/2021 - 09/30/2021. LPA learned from review of medical hx for R1 that R1 has a long hx of health-related issues that require R1 to be turned to help with treatment of pressure sores. LPA learned from an interview with R1 that R1 was left soiled overnight. Continued on LIC 9099C...
Substantiated
Estimated Days of Completion: 90
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
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 4
Control Number 27-AS-20210923104333
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: 12/22/2021
NARRATIVE
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LPA learned from an interview with R2 who shares a room with R1, that R1 was left soiled overnight while S1 worked at the facility. During the course of this investigation, LPA learned that S1 recently resigned from working at the facility as of 12/07/2021. LPA attempted a telephone interview with S1 after learning that S1 resigned her employment at the facility.

The preponderance of evidence standard has been met, therefore the above allegations is found to be


substantiated. The following deficiencies were observed (see LIC 9099-D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

Exit interview was conducted with Diana Garcia. A copy of the report LIC 9099, LIC9099C, LIC 9099-D and appeal rights were provided upon exit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20210923104333
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
87465(a)(7)
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87465 Incidental Medical and Dental Care
(a)(7) A plan for incidental medical and dental care shall be developed by each facility… When requested… a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement was not met as evidenced by:
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Licensee / Administrator agree to ensure that all medications are to be given to residents and recorded daily on the MAR for each resident. Licensee will conduct online training to all staff and submit proof of online training certificate and staff attendance sheet to LPA via email by POC due date.
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Based upon interviews with resident, staff and documents received, the licensee did not ensure that staff were administering proper medications to resident. This poses a potential threat to persons in care.
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Type B
12/31/2021
Section Cited
HSC
1569.72(b)(1)
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1569.72 Residents requiring skilled nursing or intermediate care; bedridden residents
(b)(1) "bedridden"… assistance in turning and repositioning in bed or being unable to independently transfer to and from bed, except in a facility with… sufficient care staff… as determined by… regulations. This requirement was not met as evidenced by:
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Licensee / Administrator agree to ensure that all needs and services plans are to followed for all residents by staff. Licensee will conduct online training to all staff and submit proof of online training certificate and staff attendance sheet to LPA via email by POC due date.
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Based upon interviews with residents, staff and
documents received. The licensee did not ensure that the needs of resident were being met. This poses a potential health and safety risk to persons 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) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20210923104333
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: 12/22/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/31/2021
Section Cited
CCR
87468.2(a)(8)
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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a)(8) To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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Licensee / Administrator agree to ensure that all residents will be accorded dignity, respect and free of neglect to meet the needs of residents. Licensee will conduct online training to all staff and submit proof of online training certificate and staff attendance sheet to LPA via email by POC due date.
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Based upon interviews with resident R1, R2, and staff S2, the licensee did not ensure that staff were meeting the needs for resident living in the facility. This poses a potential health and safety risk to persons 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) 263-4723
LICENSING EVALUATOR NAME: Anthony TuckTELEPHONE: (916) 708-6203
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4