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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 12/22/2025
Date Signed: 12/22/2025 12:31:39 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
10/09/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251009122801
FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 13DATE:
12/22/2025
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Facility Administrator: Sera NakalevuTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff did not prevent resident from obtaining a knife while in care.
INVESTIGATION FINDINGS:
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On 12/22/2025 at 11:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the Facility administrator Sera Nakalevu and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegation. The current census is 13. A brief interview conducted with Sera.

Allegation: Staff did not prevent resident from obtaining a knife while in care.
It was alleged that a staff did not prevent resident from obtaining a knife while in care. This investigation consisted of interviews with facility staff and residents. On 10/17/2025 LPA conducted a visit to the facility, during the visit LPA spoke with 3 out of 4 residents in care who all stated that the facility does not allow residents to use the kitchen unassisted. LPA spoke with 2 out of 2 facility staff who stated that residents are not allowed to use the kitchen unassisted.

Continuation 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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
10/09/2025 and conducted by Evaluator Shakaricka Hughes
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20251009122801

FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 13DATE:
12/22/2025
UNANNOUNCEDTIME BEGAN:
10:39 AM
MET WITH:Facility Administrator: Sera NakalevuTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff member choked resident in care.
INVESTIGATION FINDINGS:
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On 12/22/2025 at 11:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the Facility administrator Sera Nakalevu and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 13. A brief interview conducted with Sera.

Allegation: Staff member choked resident in care.
It was alleged that a staff member choked a resident in care. This investigation consisted of interviews with facility staff and residents. On 10/16/2025 LPA Hughes conducted a visit to the facility, during the visit LPA spoke with 3 out of 4 residents in care who stated that they have not observed a facility staff harm or choke a resident in care. Interview with 2 out of 2 facility staff stated that they have never physically harmed any residents in care. Interview with facility staff (S2) stated that they placed their arm close to R1’s neck to de-escalate a conflict and denied any intent to harm the resident.

Continuation 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
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-20251009122801
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: 12/22/2025
NARRATIVE
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LPA attempted to obtain police reports from Sacramento Police Dept but was unable as request for reports were never returned from the Dept. There is not enough information to corroborate this allegation therefore, the allegation is unsubstantiated.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 27-AS-20251009122801
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: 12/22/2025
NARRATIVE
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 Interview with facility staff (S1) stated that the knife that was obtained by resident (R1) was removed from the facility, Resident (R1) was allowed to use the kitchen unassisted, and obtained a knife from the kitchen without facility staff awareness. This was observed not in compliance with Title 22 regulation 87309 (a) Storage Space and Access. As the facility did not ensure that sharp objects were locked and inaccessible to residents in care.

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 evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Sera and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.
 
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 27-AS-20251009122801
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: 12/22/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2025
Section Cited
CCR
87309(a)
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87309 Storage Space and Access(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended....
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Facility agrees to remain in compliance with Title 22 regulation 87309(a) at all times. Facility agrees to ensure that all knives, sharp objects, or items that could pose a danger to residents remain in a locked storage, inaccessible to residents in care. Facility agrees to assist residents in the
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This requirement was not met as evidenced by:
The facility did not ensure a knife was locked and inaccessible to residents in care, which resulted in a incident involving a resident (R1) and facility staff (S2).
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kitchen when preparing their own meals. Facility will send a statement of acknowledgement of the Title 22 regulation 87309(a) to LPA Hughes via email by 12/23/2025.
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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: Shakaricka Hughes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/22/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5