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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 02/20/2025
Date Signed: 02/20/2025 03:43:48 PM

Document Has Been Signed on 02/20/2025 03:43 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/
DIRECTOR:		CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY: 14CENSUS: 13DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cleopatra GardinerTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 02/20/25, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Cleopatra Gardiner and explained the purpose of the visit. The current census is 13 with 3 facility staff.

This facility is a single story building licensed to serve fourteen (14) non-ambulatory residents. 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. At 1:16 PM, LPA observed a knife made accessible to residents in care. LPA observed the administrator and another staff member preparing lunch for the residents. After lunch was served, the knife was placed in the kitchen sink, and staff walked away. LPA addressed this issue with the administrator, who then locked the knife in a kitchen cabinet. Additionally, LPA observed toxic substances were stored under the kitchen sink, and it was unlock making it accessible to residents. LPA advised the administrator to secure the cabinet. LPA and the administrator also tested two residents’ call pendants, which appeared to function properly but did not emit an auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Hot water temperature was measured at 111.2 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.

Continued LIC 809-

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 7
Document Has Been Signed on 02/20/2025 03:43 PM - It Cannot Be Edited


Created By: Pang Lee On 02/20/2025 at 02:26 PM
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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview record the licensee did not comply with the section cite above. LPA observed a knife and toxins made accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 02/28/2025
Plan of Correction
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During today's visit, administrator locked up the knife and toxins. Administrator will ensure that knives and toxins are mad inaccessible to residents. Administrator will conduct storage space safety training to all facility staff. Training materials and sign in and out sheet will be email to LPA Lee. A statement of acknowledgment of reviewing the regulation cited will be email to LPA. POC due 02/28/25 end of day 5:00 PM.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


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: 02/20/2025
NARRATIVE
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 Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 02/13/25. LPA observed the facility has a has a public telephone in the kitchen. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 out of 13 residents’ medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPA requested residents and staff files for review. LPA reviewed 7 out of 13 resident files and it was incomplete. Based on records review LPA observed the following in residents’ file:

· R3 did not have LIC 601

· R4 LIC 601 was incomplete.

· R6 LIC 601 is incomplete, LIC 627C is blank and needs resident and administrator’s signature.

· R7 LIC 625 is missing administrator’s signature.

LPA Lee also reviewed 3 staff files, and they were also incomplete. Based on records review LPA observed the following in staff files:

· Staff 1(S1) LIC 501 is missing staff’s previous employment and education. LPA also did not see first aid/CPR in the staff file.

· S2 LIC 501 is missing employment and education.

· S3 does not have 20 hours of continual education for 2024.

During today’s visit, the administrator addressed and corrected the incomplete documents for both residents and staff. Administrator was able to locate S1’s first aid/CPR certificate. LPA 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 will be email to LPA during by 02/26/25 end of day 5:00 PM.

(1) LIC 308 Designation of Administrative Responsibility


(2) LIC 500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC 610D Emergency Disaster Plan
(5) Proof of Current Liability Insurance

As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.


SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 7
Document Has Been Signed on 02/20/2025 03:43 PM - It Cannot Be Edited


Created By: Pang Lee On 02/20/2025 at 03:25 PM
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: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(i)(1)(B)
87303(i)(1)(B) Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.

This requirement is not met as evidenced by:


Deficient Practice Statement
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Based on observation and interview the licensee did not comply with the section cited above. LPA and the administrator also tested two residents’ call pendants, which appeared to function properly but did not emit an auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. This poses/posed a potential health, safety, or personal rights risk to persons in care.
POC Due Date: 02/28/2025
Plan of Correction
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Administrator will inspect the signal system and ensure that it is in good repair and that it produce an auditory signal to where its alert staff. A statement of acknowledgment of reviewing the regulation cited will be email to LPA. POC statement and signal system to be in good repair due 02/28/25 end of day 5:00 PM and POC of the signal system will be conducted during a POC visit.

Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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-Lee
LICENSING EVALUATOR NAME:Pang Lee
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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