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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 11/21/2024
Date Signed: 11/21/2024 10:53:46 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
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: 9DATE:
11/21/2024
UNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Jemesa AisakeTIME COMPLETED:
09:30 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Due to staff neglect, resident choked while eating resulting in death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 11/19/2024, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to deliver complaint finding. LPA met with care giver Jemesa Aisake. LPA asked for caregiver Jemesa to call administrator Cleopatra Gardiner to informed that CCLD is present. During today's visit administrator was not present. The census is 9.

It was alleged that due to staff neglect, resident choked while eating resulting in death. Throughout the course of this investigation, the Department conducted interviews and reviewed facility records. The investigation revealed that on 06/11/2024, resident (R1) choked on food while in care at Vita Bella Elderly Care III. While (R1) was conscious and alert, staff 1 (S1) conducted the Heimlich maneuver, while S2 called 911 and followed instructions to administer cardiopulmonary resuscitation (CPR). The investigation revealed multiple staff are aware of R1’s inability to eat food independently. The staff prepare R1’s food by cutting the food in small pieces and serving soft items and per staff interviews, staff sit and feed R1 with each meal. Sacramento Fire Department paramedics arrived and pronounced R1 deceased at the scene.

Due to the above noted information, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility.

Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/21/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
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