342701192-11-13-2023-27-AS-PLEE-CXJRZV-20231113122834

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 11/13/2023
Date Signed: 11/13/2023 12:29:08 PM

Document Has Been Signed on 11/13/2023 12:29 PM - 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 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: 6	DATE:	11/13/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	11:05 AM
MET WITH:	Cleopatra Gardiner		TIME COMPLETED:	12:45 PM

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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 11/13/2023 at 11:05 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by care staff, Cleopatra Gardiner and explained the purpose of today visit. The current Census is 6 with 2 staff present in the facility.

The purpose of this visit is to follow-up on a plan of correction that was due 10/31/2023 and 11/09/2023. Care staff, Kaydia Sharp sent pictures and statement of acknowledgement of POC on 11/08/2023. LPA Lee toured and inspected the facility to ensure the deficiency previously cited on 10/26/2023 have been corrected. Licensee agreed to keep the facility floor plan as licensed. LPA Lee observed care staff moved back to room #10 and room #4 is for resident to reside in. LPA 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.

Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did not complied with the terms of the POC by POC due date 10/31/2023. A POC letter was not generated and provided to the licensee.

2. Deficiency cited under Title 22 Regulation 87211(a)(1) been cleared. The license complied with the terms of the POC by POC due date.

3. Deficiency cited under Title 22 Regulation 87506(a) been cleared. The license complied with the terms of the POC by POC due date.

4. Deficiency cited under Title 22 Regulation 87309(a) been cleared. The license complied with the terms of the POC by POC due date.

5. 4. .Deficiency cited under Title 22 Regulation 87208(a)(7)(A) been cleared. The license complied with the terms of the POC by POC due date.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/13/2023 12:29 PM - It Cannot Be Edited

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 III	FACILITY NUMBER: 342701192
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/21/2023 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465(a)(4) Incidental Medical and Dental Care...A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by:	1 2 3 4 5 6 7	Administrator agrees to conduct a medication audit and conduct a staff training on proper medication administration procedure. Administrator agrees to email POC to LPA Lee at pang.lee@dss.ca.gov by POC date 11/21/2023.
	8 9 10 11 12 13 14	Based on observation and file review, the Licensee did not ensure that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was correct. Resident’s medications did not match up with the Start date of when the resident started their medication; therefore, it is unclear if resident received their medications This posed a health immediate safety risk to residents in care.	8 9 10 11 12 13 14	Administrator agrees to send training documents used and sign-in sheet to LPA Lee by POC date 11/21/2023 by end of day.
	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) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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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 III	FACILITY NUMBER: 342701192
	VISIT DATE: 11/13/2023

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The administrator did not complied with the terms of the POC by POC due date 10/31/2023. Exit interview conducted and a copy of this report provided. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC809 (FAS) - (06/04)

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