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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 09/26/2023
Date Signed: 09/26/2023 12:04:56 PM


Document Has Been Signed on 09/26/2023 12:04 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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



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:
09/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Kayia SharpTIME COMPLETED:
12:15 PM
NARRATIVE
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On 09/26/2023, Licensing Program Analyst (LPA) Pang Lee arrived at facility unannounced to
conduct a case management visit. LPA met with direct care staff, Kaydia Sharp and explained the purpose of the visit. The census is 10 with 2 care staff. Administrator Mark LaBella was not present during today's visit.

The purpose of this case management is due to learn deficiencies during complaint investigation with complaint control number 27-AS-20230925082209. LPA Lee toured the facility and checked on residents’ welfare. At 8:46 AM, LPA Lee observed the emergency exit gate was locked. At 9:31 AM, LPA Lee also observed that the fire extinguisher was last service on 09/21/2023. LPA Lee advised direct care giver, Kaydia Sharp that the emergency exit cannot be locked at any time. LPA Lee also advised direct care giver, Kaydia Sharp that the fire extinguisher needs to be re-service and that it is past due. LPA Lee 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.

The following deficiency was observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of the appeals rights, LIC 809 report, and LIC 809-D page was given to the facility.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
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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Document Has Been Signed on 09/26/2023 12:04 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/03/2023
Section Cited
CCR
87202

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87202(a) Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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The facility staff unlocked the emergency exit door during the visit. Administrator agrees to conduct a fire clearance training for all staff. Administrator will also write a statement of acknowledging that all facility Saff have read and understood regulations being cited. Administrator will send LPA Lee copies of training agenda and sign in sheet of all staff that attended the training.
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Based on observation and facility inspection, the Licensee did not ensure the emergency fire exit door was kept unlock. This posed an immediate health and safety risk to residents in care.

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Administrator will email LPA Lee POC pang.lee@dss.ca.gov POC by POC date of 10/03/2023 by 5:00 PM by end of day.
Type A
09/28/2023
Section Cited
CCR87202(a)

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87202(a) Fire Clearance All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
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Administrator agrees to get the fire extinguisher serviced and send document that fire extinguisher has been service. Administrator will send POC by POC due date 09/28/2023 by 5:00 PM by end of day.
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Based on observation and facility inspection, the Licensee did not ensure the fire extinguisher was current. Fire extinguisher was last serviced on 09/21/2023. This posed an immediate health and safety risk to residents in care.
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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.
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2023
LIC809 (FAS) - (06/04)
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