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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:13:08 PM


Document Has Been Signed on 10/26/2023 03:13 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: 13DATE:
10/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Kaydia Sharp, Cleopatra Gardiner and Mark LabellaTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/26/2023 at 8:00 AM to conduct a case management visit. LPA Lee met with direct care staff Kaydia Sharp and Cleopatra Gardiner and explained the purpose of the visit. Approximately around 8:45 AM, administrator, Mark Labella arrived at the facility. LPA Lee spoke with administrator regarding the purpose of today visit and the deficiencies observed on 10/25/2023. At 10:03 AM, LPA Lee toured the facility and reviewed staff and resident files.

The purpose of the visit is to follow up on deficiencies learned during complaint investigation 27-AS-20231023155603. Through the complaint investigation, it was learned that the facility did not follow its plan of operations. The licensee did not ensure to follow the facility sketch. Through observations and interviews it was learned that on 10/22/2023, the facility two live in staff moved and resided in a resident room #4 and a resident, then was moved to the staff room #10. Furthermore, the licensee did not submit this change to the department for approval.

At 12:29 PM, LPA Lee observed a Lysol All Purposed Cleaner in a bathroom #2 unlocked. At 12:38 PM, LPA Lee observed another Lysol All Purposed Cleaner on top of the dining table while two residents was eating lunch. LPA Lee also observed another Lysol All Purposed Cleaner in the resident main bathroom counter made accessible to residents in care.

At 1:23 PM, LPA Lee requested resident 1 (R1) file for reviewed. It was learned that the following documents were not filled out and left blank; however, the documents had both facility staff and resident signature: LIC 603A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan.

Continued- LIC 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR NAME: Pang LeeTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 5


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
VISIT DATE: 10/26/2023
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On 10/24/2023, via telephone, LPA Lee spoke to administrator, Mark Labella in regards to the facility LIC 500 Personnel Report. Per facility LIC 500 it states that administrator will be at the facility from Monday to Thursday from 10:00 AM to 3:00 PM. Administrator confirms that he is not always at the facility during facility hours on the LIC 500. LPA Lee has been out to this facility on 10/25/2023, 10/24,2023, 10/05/2023, 10/20/23, 10/05/2023, 09/26/2023, 09/12/2023 and 06/06/2023 and during all these visit LPA Lee has not seen administrator Mark Labella in the facility per LIC 500. Furthermore, LPA Lee interviewed 10 out of 10 residents who stated that they did not know who the administrator was and have not seen the administrator in the facility. It was also learned through interviews with two outside agency who confirmed with LPA Lee that the administrator is hardly at the facility.

During today’s visit LPA Lee reviewed facility unusual incident reports (UIR). It was learned that the facility had documentations in the facility of (UIR). Records reviewed show that the facility had 6 (UIR) for the month of October 3 (UIR) for the month of September, and 3 (UIR) for the month of August; however, LPA Lee reviewed the department Electronic Facility Files, and it was learned that there was no documentation of any (UIR) reported to the department for the month of August, September, and October; therefore, the facility is not following reporting requirements. Moreover, when LPA Lee question administrator, Mark Labella he was not able to give LPA Lee sufficient reason or proof that all these (UIR) has been faxed and reported to the department.

The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeal rights were 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/26/2023 03:13 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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
87405(a)

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87405(a) Administrator - Qualifications and Duties
(a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours…

This requirement is not met as evidenced by:
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Administrator agrees to read regulation 87405(a) and submit a signed declaration of understanding. The administrator will review LIC 500 Personnel Report for accuracy and ensure the administrator is present at the facility for a sufficient number of hours.
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Based on interviews, records review and observations, the licensee did not comply with the section cited above. The licensee did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.
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 The administrator will email POC to LPA Lee by POC due date 11/02/2023 by 5:00 PM end of day.

Type B
11/02/2023
Section Cited
CCR87208(a)(7)(A)

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87208(a)(7)(A) Plan of Operation
a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:
(7) Sketches, showing dimensions, of the following:

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The administrator agrees to email updated facility sketch and request approval for plan of operation changes. The administrator agrees to review the regulation being cited today and write a statement acknowledging administrator understand the regulation being cited and email POC to LPA Lee at pang.lee@dss.ca.gov by POC Date 11/02/2023 by end of day 5:00 PM.
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(A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for non ambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e)

This requirement is not met as evidenced by:

Based on observations and interview this requirement was not met evidence by: The administrator did not ensure the facility maintained a current plan of operation. The administrator allowed two care staff to reside in a resident room. Licensee did report any room changes and did not maintain a current plan of operation by not updating facility sketch and did not submit changes to CCLD. This posed a potential risk to residents in care. and therefore, another resident was moved to reside in care staff room, which poses/posed a potential health, safety, or personal rights to person 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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 10/26/2023 03:13 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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/02/2023
Section Cited
CCR
87211(a)(1)

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87211(a)(1) Reporting Requirements
a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement is not met as evidenced by:
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The administrator agrees to read the regulation being cited today and submit a signed declaration of understanding. The administrator will also train all facility staff in regards to the regulation being cited today and provided LPA Lee documents used for the training. The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 11/09/2023 by end of day 5:00 PM

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Based on file review and interviews the Licensee did ensure staff were meeting reporting requirements and submitting LIC 624 Unusual incident reports that include elder abuse within 24 hours to CCLD. This posed a potential health and safety risk to residents in care.

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Type B
11/02/2023
Section Cited
CCR87506(a)

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87506(a) Resident Records
(a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

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The administrator agrees to provide training on resident records. Administrator write a statement of declaration of the regulation cited and provide LPA Lee documents used for staff training along with training sign in sheet. The administrator will also write a statement acknowledging and understanding the regulation being cited today. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by POC date 11/09/2023 by end of day 5:00 PM. On 10/25/2023 at 7:38 PM, care staff Kaydia Sharp emailed LPA Lee updated LIC 603 A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan for resident 1 (R1).




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Based on observations and interview administrator did not ensure that resident 1 (R1) It was learned that the following documents were not filled out and left blank with facility staff and resident signature: LIC 603 A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan. The administrator did not ensure a separate and complete current record was maintained for (R1). This posed a potential 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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/26/2023 03:13 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: 10/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/02/2023
Section Cited
CCR
87309(a)

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87309(a) Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement was not met as evidence by:
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The administrator agrees to provide training on Storage space regulation and provide LPA Lee documents used for staff training along with training sign in sheet.
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Based on observation, Administrator did not ensure that Lysol All Purpose Cleaner was made accessible to residents in care, which This poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.

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 The administrator will also write a statement acknowledging and understanding the regulation being cited today. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by POC date 11/09/2023 by end of day 5:00 PM.

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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: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5