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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 12/01/2022
Date Signed: 12/01/2022 03:41:05 PM


Document Has Been Signed on 12/01/2022 03:41 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833



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:15CENSUS: 0DATE:
12/01/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Mark Labella & Penina TuimaualugaTIME COMPLETED:
04:00 PM
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Licensing Program Analysts (LPA) Avelina Martinez and Pang Lee and Licensing Program Manager arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Avelina Martinez met with Mark Labella and Penina Tuimaualuga who assisted LPAs and LPM in today’s inspection.

LPAs and LPM toured the facility with Mark Labella and Penina Tuimaualuga. During today's visit, the Applicant changed the layout of the facility, which shall be inspected and cleared by the Fire Department.

Upon the suggestion of the Applicant the following changes will be made:

  • Bedroom 9: An entrance door will need to constructed before being licensed.
  • Bedroom 10: Will be converted to a staff room, which shall be inspected and cleared by the Fire Department.
  • Bedroom 5: Will be converted to a two non-ambulatory room, which shall be inspected and cleared by the Fire Department.
  • Bedroom 2: Will be converted to a single room, which shall be inspected and cleared by the Fire Department.
Due to layout being changed a new STD 850 will need to be submitted to the Department.

Facility Corrections:
  • Repair Window in room 1 and 2.
  • Repair exterior steel gate.
  • Outside Patio needs a ramp for wheelchair access.
  • Outside courtyard needs a canopy
  • Outside gutter need to be repaired
  • Room needs an electrical cover plate
  • Updated facility sketch
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
FACILITY NAME: VITA BELLA ELDERLY CARE III
FACILITY NUMBER: 342701192
VISIT DATE: 12/01/2022
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The Department will return at a later date to complete the prelicensing. The applicant has not passed the pre-licensing component of the application process today.

An exit interview was conducted, and a copy of this report was given to the applicant.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2022
LIC809 (FAS) - (06/04)
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