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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 02/09/2023
Date Signed: 02/09/2023 09:28:38 AM


Document Has Been Signed on 02/09/2023 09:28 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
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:14CENSUS: 0DATE:
02/09/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mark Labella and Penina TuimaualugaTIME COMPLETED:
09:45 AM
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On 02/09/2023, Licensing Program Analyst (LPA) Avelina Martinez arrived announced to conducted a Pre-Licensing Inspection of the facility to ensure compliance with Title 22 regulations. LPA Martinez met with Mark Labella and Penina Tuimaualuga who assisted LPA Martinez in today’s inspection.

LPA Martinez toured the facility with Mark Labella and Penina Tuimaualuga. During today's visit, all corrections were completed, and the applicant has passed the pre-licensing visit.

  • Room 2 window needs to be replaced. Window has crack. Completed
  • Screens were installed in rooms 1, 2, 3, 5, 10, and kitchen windows, dinning room windows, and living room windows. Completed
  • Outside ramp needs to fastened. Completed
  • Floor repair at rooms 6,7,8 Completed
  • Room 9 AC protector needs to fasten. Completed
  • Repair exposed wires throughout the facility. Completed
  • Open plastic cover to clear for fire escape route Completed
  • Add an electric cover plate in storage area by rooms 7/8/9 and remove debris. Completed
  • Remove Dead bolt from fire escape exterior door. Completed
  • Repair Windows in room 1 and 2. Completed
  • Repair exterior steel gate. Completed
  • Outside Patio needs a ramp for wheelchair access. Completed
  • Outside courtyard needs a canopy. Completed
  • Outside gutter need to be repaired. Completed
  • Rooms need an electrical cover plate Completed
  • Updated facility sketch. Completed

Continued...
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Avelina MartinezTELEPHONE: (916) 431-8935
LICENSING EVALUATOR SIGNATURE:
DATE: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/09/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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: 02/09/2023
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The applicant has passed the pre-licensing component of the application process. LPA Martinez will notify the Central Application Bureau (CAB) that the pre-licensing has been completed and passed. The Applicant reported he has completed Component 3 previously, as a result, Component 3 was waived for this pre-licensing.

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: 02/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2