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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 09/18/2024
Date Signed: 09/18/2024 04:00:20 PM

Substantiated


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
07/22/2024 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20240722155157
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: 10DATE:
09/18/2024
UNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Aisake Jemesa and Alita Natoga TIME COMPLETED:
04:11 PM
ALLEGATION(S):
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Incident Reports are not reported as required.
Administrator does not spend sufficient number of hours at the facility.
INVESTIGATION FINDINGS:
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On 09/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Aisake Jemesa and Alita Natoga and explained the purpose of the visit. LPA called licensee Mark Lablla and left a message. LPA also called administrator Cleopatra Gardiner and explained the purpose of this visit is to deliver complaint findings for the allegations above. The current census is 10 with 2 facility staff. Approximately 20 minutes later administrator arrived at the facility. Licensee Mark Labella who was the previous administrator was not present at the facility.

Allegation: Incident Reports are not reported as required.
It was alleged that incident reports are not reported as required. This investigation consisted of interview with facility staff and records reviewed. LPA Lee interviewed 4 facility staff who stated that incident reports are reported to the administrator Mark Labella and that the administrator then will report incident reports to the department. During 07/22/24 facility visit, LPA Lee observed a binder with multiple handwritten LIC 624 incident reports.
Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
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 4
Control Number 27-AS-20240722155157
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: 09/18/2024
NARRATIVE
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LPA Lee requested copies of the incident reports from the binder. LPA Lee was provided with 23 LIC 624 Incident Report for the year of 2023 and 9 LIC 624 Incident Report for the year of 2024. LPA Lee reviewed incident report and multiple incident report does not indicate that the incident report was reported to the department. Based on incident report that was provided to LPA there were 3 Absent Without Leave (AWOL), 3 deaths, 1 resident found unresponsive, 2 wound care concerns where resident was sent out to the hospital and an incident where a staff found a resident with a knife in resident’s hand trying to slit resident’s wrist. LPA Lee also reviewed the department’s Electronic Facility Files where facilities incident report that are faxed to the department are saved and there was no incident report in the Electronic Facility Files from Vita Bella Elderly Care III. Furthermore, the facility was not able to provide proof of the multiple incident reports as ever faxed or reported to the department. Moreover, on 09/03/2024, LPA Lee reached out to Licensee Mark Labella regarding an incident where a resident choked and then was pronounced decease, to see if the incident was reported to the department. On 09/09/2024, administrator emailed LPA Lee a screen shot of a document faxed to the department; however, LPA Lee was not able to confirm what was faxed to the department since it was only a screen shot. On 09/09/24, LPA Lee requested to have the fax forwarded to LPA Lee since the facility uses Fax.com Email to fax documents, the administrator was not able to forward the fax to LPA Lee and provide proof that multiple incident reports were reported to the department.

Allegation: Administrator does not spend sufficient number of hours at the facility.

It was alleged that Administrator does not spend sufficient number of hours at the facility. This investigation consisted of interview with facility staff and residents, observations and records reviewed. LPA Lee interviewed 4 facility staff who confirmed that administrator Mark Labella comes to the facility once a week to tour the facility and provided the facility with materials that are needed. The facility staff confirmed that the administrator is at the facility 4 times a month. LPA Lee also spoke to two individuals who used to work at Vita Bella Elderly Care III, who stated that administrator is not at the facility and only see the administrator 3-4 times a month. LPA Lee also interviewed 6 residents who stated that they don’t know the name and who the administrator is and thought that designated/caregiver staff Cleopatra Gardiner was the administrator. Moreover, based on records review, LIC 500 the administrators’ scheduled is Tuesday from 2:00 PM to 6:00 PM, Thursday from 12:00 PM to 5:00 PM, Friday from 2:00 PM to 6:00 PM. Based on previous facility visit and observation, LPA Lee did not observe the administrator Mark Labella present in the facility during the following facility visits:06/06/23, 09/12/23, 09/26/23, 10/05/23, 10/20/23, 10/24/23, 10/25/23, 11/13/23, 11/21/23, 01/10/24, 01/30/24, 03/05/24, 04/11/24, 05/16/24, and 07/24/24. As of 07/24/2024, LPA Lee still have not receive any LIC 624 Incident Reports from the facility.

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-D, per Title 22 Regulations. An exit interview was conducted and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 27-AS-20240722155157
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: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87211(a)(1)(D)
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87211(a)(1)(D) Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence…
(D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
This requirement is not met as evidenced by
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Administrator agrees to conduct a reporting in-service training by 09/27/24. Training materials and staff sign in sheet will also be email to LPA Lee.
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Based on the file reviews and interviews, the Licensee did not ensure facility reported multiple incidents reports to CCLD. This posed a potential health and safety risk to residents in care.
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Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.
Type B
09/27/2024
Section Cited
CCR
87405(a)
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87405(a) Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility…

This requirement is not met as evidenced by
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Licensee/Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.
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Based on observation and facility visits, the Administrator has not been at facility for a sufficient number of hours and adhere to the facility LIC 500 Personnel Report.
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 27-AS-20240722155157
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: 09/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/27/2024
Section Cited
CCR
87405(a)
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THIS REPORT IS AMENDED TO REMOVED THE DOUBLE CITATION FOR 87405(a).
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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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4