342701192-10-20-2023-27-AS-KHOS-CWWNW4-20231024104855

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 10/20/2023
Date Signed: 10/20/2023 12:59:18 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2023 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20230907092938

FACILITY NAME:	VITA BELLA ELDERLY CARE III		FACILITY NUMBER:	342701192
ADMINISTRATOR:	LABELLA, MARK		FACILITY TYPE:	740
ADDRESS:	6700 SUN RIVER DR		TELEPHONE:	(916) 490-0237
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	14	CENSUS: 13	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Kaydia Sharp and Cleopatra Gardnier		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff drugged residents’ food or drinks while in care.

INVESTIGATION FINDINGS:

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On 10/20/2023 at 11:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff, Kaydia Sharp and Cleopatra Gardiner and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 13 with three facility staff. Administrator Mark Labella was not present in the facility during today vist. A brief interview with conducted with both care giver, Kaydia Sharp and Cleopatra Gardiner.

Allegation: Staff drugged residents’ food or drinks while in care.
It was alleged that the staff drugged residents’ food or drinks while in care. This investigation consisted of records reviewed, interviews with staff, residents, Ombudsman and resident 1 (R1)’s psychiatrist. LPA Lee interviewed 7out of 8 residents who have no concern in regards to staff drugging residents’ food and drink. Throughout the course of the investigation, it was learned that (R1) psychiatrist stated (R1) received a point of care test at the hospital on 08/29/2023.
Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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-20230907092938

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 III	FACILITY NUMBER: 342701192
	VISIT DATE: 10/20/2023

NARRATIVE

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The test showed that (R1) tested positive for methamphetamine and that it was possible for (R1) medications, Zyprexa, that (R1) is prescribe to potentially cause (R1) to have a false-positive test for methamphetamine. The investigation also revealed that (R1) denies that the facility staff is drugging (R1).

Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegation is unsubstantiated. There are no deficiencies noted or cited per California Code Regulation, TITLE 22.

Exit interview was conducted with the facility staff and a copy of this report was left with care staff Kaydia Sharp..

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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