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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 11/27/2024
Date Signed: 11/27/2024 10:03:57 AM

Document Has Been Signed on 11/27/2024 10:03 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 CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR/
DIRECTOR:		CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 14CENSUS: 9DATE:
11/27/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:QJemesa AisakeTIME VISIT/
INSPECTION COMPLETED:
10:15 AM
NARRATIVE
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Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived at this facility unannounced on 11/27/2024 to conduct a case management visit. LPAs met with direct care staff Jemesa Aisake and explained the purpose of the visit. The purpose of this visit is to amend visit report dated on 11/21/2024 to generate LIC 809-D and civil penalty. The census is 9.

Based on records review it was learned that resident 1 (R1) was admitted to the facility on 11/09/2023. According to R1’s LIC 625 Appraisal/Needs and Service Plan, there was no indication that R1 required assistance with feeding. However, based on an LIC 624 incident report dated 05/22/2024, R1 was admitted to Methodist Hospital of Sacramento after care staff observed R1 coughing profusely during a meal. The coughing persisted even as staff assisted with feeding. The Methodist Hospital Emergency Documentation recommended that R1 be placed on a soft, bite-sized diet with thin liquids. However, the facility did not update R1’s LIC 625 Appraisal/Needs and Service Plan to reflect this recommendation. The interviews with care staff, revealed staff were aware of R1’s dietary needs, including the need for food to be cut into small pieces, as well as R1’s tendency to eat too quickly. Despite this, the facility did not update R1’s LIC 625 Needs and Service Plan and Reappraisals to reflect these changes. The facility administrator did not report the changes to R1’s physicians so that the physician’s report could also be updated. Additionally, R1 was accepted into and retained at the home, where R1 require assistance with all activities of daily living, as outlined in R1's LIC 625 Needs and Service Plan and confirmed during an interview with Administrator Cleopatra Gardiner and direct care staff Jemesa Aisake. Furthermore, there were no exceptions made for R1, as R1 is not receiving hospice care.

On 11/21/2024, LPA Lee observed a volunteer staff (VS) present in the facility. It was observed that VS was assisting with sweeping, changing residents’ sheets, socializing with the residents, and shadowing the caregivers. Based on records review VS is does not have a California clearance and is not associated to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2024
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 III
FACILITY NUMBER: 342701192
VISIT DATE: 11/27/2024
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On 11/21/2021, LPA Lee also delivered an Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately.

The following deficiency were 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 this LIC 809 report, exclusion letter and appeal rights were given to the facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/27/2024 10:03 AM - It Cannot Be Edited


Created By: Pang Lee On 11/27/2024 at 08:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 11/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/04/2024
Section Cited
CCR
87411(g)(2)

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87411(g)(2)Personnel Requirements – General
(g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall:
(2) Request a transfer of a criminal record clearance...
This requirement was not met as evidence by:
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Administrator agrees to conduct a Personnel Requirements in service training with facility staff. Training materials and sign in sheets will be provided to LPA.
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This requirement was not met as evidence by: Based on interviews, observations and record review, on 11/21/24 the facility did not ensure the volunteer staff has a California clearance and associated to the facility. This posed an immediate health and safety risk to R1.
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Administrator will also review the regulation cited and provide LPA a statement of acknowledgement and understating of the regulation cite. POC due to LPA by 12/04/24 end of day 5:00 PM.
Type B
12/04/2024
Section Cited
CCR87463(a)(3)

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87463(a)(3) Reappraisals: the pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...reappraisals shall document changes in the resident's physical, medical, mental, and social condition...Any illness, injury, trauma, or change in the health care needs
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Administrator agrees to conduct a reappraisal in service training with facility staff. Training materials and sign in sheet will be provided to LPA.
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This requirement was not met as evidence by:
Based on interviews and record review, the facility did not conduct a reappraisal after R1 returned from the hospital. This posed an immediate health and safety risk to R1.

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 Administrator will also review the regulation cited and provide LPA a statement of acknowledgement and understating of the regulation cite. POC due to LPA by 12/04/24 end of day 5:00 PM.
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-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 11/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/27/2024


LIC809 (FAS) - (06/04)
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