342700921-6-13-2022-27-AS-KHOS-CFELCC-20220615083808

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342700921
Report Date: 06/09/2022
Date Signed: 06/13/2022 09:22:43 AM

Substantiated

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
06/06/2022 and conducted by Evaluator Avelina Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20220606144450

FACILITY NAME:	VITA BELLA ELDERLY CARE II		FACILITY NUMBER:	342700921
ADMINISTRATOR:	DIANA GARCIA		FACILITY TYPE:	740
ADDRESS:	8362 NEW POINT DR		TELEPHONE:	(916) 821-4423
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	6	CENSUS: 4	DATE:	06/09/2022
		UNANNOUNCED	TIME BEGAN:	10:06 AM
MET WITH:	Diana Garcia		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Staff failed to prevent Resident being hit by another resident.

INVESTIGATION FINDINGS:

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On 6-09-2022 at 10:30 AM, Licensing Program Analyst (LPA) Avelina Martinez conducted an unannounced facility visit in regards to a complaint investigation with the above allegation. LPA met with Diana Garcia and explained the purpose of today's visit.

Throughout the course of the investigation, LPA Martinez obtained facility records and conducted interviews. It was learned resident 1(R1) struck resident 2 (R2) on the eye. The incident occurred in R2's room, and staff 1 (S1) intervened after R1 struck R2. S1 provided first aid care to R2's eye injury. R2's eye injury has healed. Since this incident occurred, the facility has increased monitoring for both residents and reassessments are in the process of being completed. Both residents have worked on their relationship, and both residents reported having no issues or concerns. Staff will also be required to complete aggressive behavior training.

Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220606144450

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: 06/09/2022

NARRATIVE

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As a result of this investigation, the Department finds this allegation to be Substantiated. A finding that the complaint is substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20220606144450

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: 06/09/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/23/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2)Personal Rights of Residents in All Facilities: Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations...	1 2 3 4 5 6 7	The administrator agrees to conduct behavior training for staff, and to increase monitoring for R1 and R2. Administrator will also conduct reassessments for R1's and R2's behaviors. By POC Date 6/23/22, and will email LPA Documents by 6/23/22.
	8 9 10 11 12 13 14	This requirement was not met as evidence by...Based on interviews R2 was not accorded a safe accommodations as R2 was struck on the eye by R1. This posed a potential health and safety risk to R1.	8 9 10 11 12 13 14
	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: Avelina Martinez	TELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2022

LIC9099 (FAS) - (06/04)

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