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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 01/30/2024
Date Signed: 01/30/2024 09:43:55 AM


Document Has Been Signed on 01/30/2024 09:43 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 IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:LABELLA, MARKFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 12DATE:
01/30/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
08:24 AM
MET WITH:Cleopatra GarnierTIME COMPLETED:
10:00 AM
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 8:24 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by direct care staff Cleopatra Garnier and explained the purpose of today visit. The current Census is 12 with 2 staff present in the facility. A brief telephone call was made to administrator Mark Labella in regard to POC training materials.

The purpose of this visit is to follow-up on a plan of correction that was due 11/21/2023. On 11/17/2023 direct care staff Kaydia Sharp emailed LPA Lee training sign in sheet; however, the training sign in sheet is missing staff signatures acknowledging that those staff received training. On 12/06/2023 LPA Lee emailed both direct care staff Kaydia and administrator Mark Labella in regard to (POC) is missing training materials used for the training. On 01/30/2024 at 8:46 AM, administrator Mark emailed LPA Lee training materials that was used during the training on 11/16/2023. 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 been cleared. The license did comply with the terms of the POC during today’s visit.

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 214-5136
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 508-9726
LICENSING EVALUATOR SIGNATURE:
DATE: 01/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/30/2024
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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