342701192-6-6-2023-27-AS-PLEE-CSJRVJ-20230606132133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 06/06/2023
Date Signed: 06/06/2023 01:21:39 PM

Document Has Been Signed on 06/06/2023 01:21 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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	VITA BELLA ELDERLY CARE III		FACILITY NUMBER:	342701192
ADMINISTRATOR:	LABELLA, MARK		FACILITY TYPE:	740
ADDRESS:	6700 SUN RIVER DR		TELEPHONE:	(916) 490-0237
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	14	CENSUS: 10	DATE:	06/06/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Kaydia Sharp		TIME COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analysts (LPA) Pang Lee and Avelina Martinez arrived at the facility on 06/06/2023 at 12:30 PM to conduct an unannounced Plan of Correction (POC) visit. LPAs met with Kaydia Sharp. LPAs explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due 06/02/2023. During today's visit, LPAs reviewed residents and staff files. LPAs reviewed training documents for staffs and LPAs reviewed residents’ admission agreements and addendum. LPAs toured and inspected the facility to ensure deficiency previously cited on 05/19/2023 have been corrected.

LPAs reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility.

Based upon this inspection, LPA Lee observed the following:
1. Deficiency cited under Title 22 Regulation 87208(a) has been cleared. Licensee complied with the terms of the POC by POC due date.
2. Deficiency cited under Title 22 Regulation 87303 has been cleared. Licensee complied with the terms of the POC by POC due date.
3. Deficiency cited under Title 22 Regulation 87405(d)(2) has been cleared. Licensee did complied with the terms of the POC by POC due date.

4. Deficiency cited under Title 22 Regulation 87411(g) has been cleared. Licensee did complied with the terms of the POC by POC due date.

5. Deficiency cited under Title 22 Regulation 87202 has been cleared. Licensee did complied with the terms of the POC by POC due date.

Continued LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

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
SACRAMENTO AC/SC, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: VITA BELLA ELDERLY CARE III	FACILITY NUMBER: 342701192
	VISIT DATE: 06/06/2023

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6. Deficiency cited under Title 22 Regulation 87412(c)(1)(A) has been cleared. Licensee did complied with the terms of the POC by POC due date.

7. Deficiency cited under Title 22 Regulation 87506(a) has been cleared. Licensee did complied with the terms of the POC by POC due date.

Proof of correction was submitted by email on 06/01/2023. Licensee complied with the terms of the POC by POC due date. Facility was provided with POC cleared letter. An exit interview conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang Lee	TELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:	DATE: 06/06/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/06/2023

LIC809 (FAS) - (06/04)

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