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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 10/24/2023
Date Signed: 10/24/2023 10:31:14 AM

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
09/29/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230929123535
FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 13DATE:
10/24/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Kaydia Sharp and Cleopatra GardinerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff not keeping facility free of pests.
Staff not keeping facility free from odor.
INVESTIGATION FINDINGS:
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On 10/24/2023 at 8:05 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 findings for the allegations above. The current census is 13 with three facility staff. A brief interview were conducted with both caregivers Kaydia and Cleopatra. Administrator Mark Labella was not present during today visit.

Allegation: Staff not keeping facility free of pests.
It was alleged that staff are not keeping the facility free of pests. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents who have no concern with the facility having pests or roaches. 10 of 10 residents also shared that they have not witnessed any roaches or pests in the facility and in their room. LPA Lee conducted a complaint follow-up investigation on 09/12/2023, 09/26/2023, 10/05/2023 and 10/20/23 and LPA Lee did not observe any roaches or pests in the facility.
Continued LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
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 5
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
09/29/2023 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20230929123535

FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 13DATE:
10/24/2023
UNANNOUNCEDTIME BEGAN:
08:10 AM
MET WITH:Kaydia Sharp and Cleopatra GardinerTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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2
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9
Staff mishandled resident’s medication.
INVESTIGATION FINDINGS:
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On 10/24/2023 at 8:05 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 findings for the allegations above. The current census is 13 with three facility staff. A brief interview were conducted with both caregivers Kaydia and Cleopatra. Administrator Mark Labella was not present during today visit.

Allegation: Staff mishandled resident’s medication.
It was alleged that Staff mishandled resident’s medication. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 8 out of 10 residents who have no concern with staff mishandling resident’s medication. On 10/05/2023 LPA Lee and direct care staff Kaydia Sharp and Cleopatra Gardiner reviewed four residents LIC 622A, Medication Administration Record (MAR) sheets. It was learned that 1 out of 4 MAR sheets were not complete.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 27-AS-20230929123535
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: 10/24/2023
NARRATIVE
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 It was learned that (R1) had medication for Quetiapine Fumarate, 25 MG and the medication was not on (R1) MAR sheet; therefore, it is unclear if (R1) received the medication. The investigation also revealed that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was incorrect when LPA Lee and care staff Kaydia and Cleopatra counted the residents’ medications. Resident’s medications did not match up with the Start date of when the resident started the medication; therefore, it is unclear if resident received their medications. It was also learned that on the LIC 622 CSMDR medication start date is not filled out correctly. Care staff Kaydia had to call the pharmacy to determine the start date for 3 out 4 resident medications. Per administrator, Mark Labella and both care giver Kaydia and Cleopatra stated that administrator, Mark Labella come to the facility once a week to audit medication; however on 10/05/2023 3 out of 4 residents medication had discrepancy.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099. An exit interview was conducted with Kaydia and Cleopatra and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20230929123535
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2023
Section Cited
CCR
87465(a)(4)
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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:
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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 10/31/2023.
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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.
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Administrator agrees to send training documents used and sign-in sheet to LPA Lee by POC date 10/31/2023 by end of day.
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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) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 27-AS-20230929123535
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: 10/24/2023
NARRATIVE
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Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free of pests.

Allegation: Staff not keeping facility free from odor.
It was alleged that staff are not keeping the facility free from odor. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents who have no concern with the facility having an odor. 10 of 10 residents also shared that they have not witnessed any odor in the facility and in their room. LPA Lee conducted a complaint follow-up investigation on 09/12/2023, 09/26/2023, 10/05/2023 and 10/2023 and LPA Lee did not observe the facility to be odorous. Furthermore, during these complaint follow-up visit, LPA Lee observed facility staff sweeping, mopping, doing the dishes and laundry.

Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free from odor.

An exit interview was conducted with both care staff Kaydia and Cleopatra and this report was given to the facility at the end of the visit.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5