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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342700919
Report Date: 01/28/2025
Date Signed: 01/28/2025 11:38:53 AM

Document Has Been Signed on 01/28/2025 11:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:VITA BELLA ELDERLY CAREFACILITY NUMBER:
342700919
ADMINISTRATOR/
DIRECTOR:		LABELLA, MARKFACILITY TYPE:
740
ADDRESS:4082 73RD STREETTELEPHONE:
(916) 594-7250
CITY:SACRAMENTOSTATE: CAZIP CODE:
95820
CAPACITY: 10CENSUS: 6DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:33 AM
MET WITH:Aliti Waqalala and Adilina Tuiloma TIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 01/28/25 at 8:33 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff Aliti Waqalala and Adilina Tuiloma and explained the purpose of the visit. Facility staff called administrator Mark Labella to informed that CCLD is present. A brief interview was conducted with administrator via telephone. Administrator was not present today and caregivers Alita and Adilina assisted with today’s inspection. Administrator certificate # is 7036077740 and will expire on 07/29/26. The current census is 6 with 2 facility staff.

This facility is a two-story building licensed to serve eight (8) non-ambulatory residents and two (2) ambulatory residents in bedroom #5 only. The facility is also approved for 1 hospice resident. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present.

LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. Hot water temperature was measured at 105.6 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 01/22/25. The last fire drill was conducted on 11/19/24. LPA observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat observed at 69 degrees Fahrenheit.

Continued LIC 809-C
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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 SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: VITA BELLA ELDERLY CARE
FACILITY NUMBER: 342700919
VISIT DATE: 01/28/2025
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LPA observed toxins located in cabinet sink and kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 out of 6 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all of the required components. LPA requested and staff files for review. LPA reviewed 5 out of 6 resident files and 3 staff files and they were complete. 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 documents were given to LPA during today's visit.
(1) LIC 308 Designation of Administrative Responsibility
(2) Copy of Administrator Certificate

The following documents will be email to LPA Lee by
(1) Current LIC 610 Emergency Disaster Plan
(2) Proof of Current Liability Insurance
(3) Current LIC 500 Personnel Report

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report and LIC 9102 Technical Assistant was provided.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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