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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700921
Report Date: 03/13/2025
Date Signed: 03/13/2025 11:37:40 AM

Document Has Been Signed on 03/13/2025 11:37 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VITA BELLA ELDERLY CARE IIFACILITY NUMBER:
342700921
ADMINISTRATOR/
DIRECTOR:		MARIE TAYLOR TRIMMINGHAMFACILITY TYPE:
740
ADDRESS:8362 NEW POINT DRTELEPHONE:
(916) 667-8409
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 6CENSUS: 6DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Marie TaylorTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 03/12/25, Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPAs met with administrator Marie Taylor and explained the purpose of the visit. Administrator assisted with today’s visit. Administrator certificate # is 6070952740 and will expire on 06/23/26. The current census is 6 with 1 facility staff.

This facility is a single story building licensed to serve six (6) non-ambulatory residents and hospice waiver for (1). LPAs inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPAs observed the facility to be free of odor, clean and in good repair. LPAs observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPAs toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 105.3 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 08/07/24. The last fire drill was conducted on 02/13/24. Administrator was aware that fire drill is conducted every 3 months. LPAs observed the facility has a has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPAs observed toxins located in the garage and underneath the kitchen cabinet and kept locked and inaccessible to residents. LPAs observed sharp knives kept locked under the kitchen sink and inaccessible to residents. LPAs checked medication storage and found medication to be locked away and inaccessible to residents. LPAs reviewed 3 out of 6 resident medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE II
FACILITY NUMBER: 342700921
VISIT DATE: 03/13/2025
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 LPAs requested resident and staff files for review. LPAs reviewed 5 out of 6 resident files, and 2 out of the 5 resident files were missing TB documentation. Per administrator the two resident does have their TBs completed and are misfiled. During today's visit, administrator was working on locating the TB. Administrator will provided proof of TB by end of day today 03/13/25 5:00 PM. LPAs reviewed 2 staff files, and it was complete. LPAs reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

The following documents will be email to LPA by 03/20/25 end of day 5:00 PM:

(1) Copy of Administrator Certificate

(2) LIC 610 Current Emergency Disaster Plan

(3) Proof of Current Liability Insurance

(4) LIC 500 Current Personnel Report

As a result of this annual visit, the facility is in compliance with Title 22 Regulation. An exit interview was conducted with administrator, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
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