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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701192
Report Date: 03/04/2025
Date Signed: 03/04/2025 11:14:43 AM

Document Has Been Signed on 03/04/2025 11:14 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: 14DATE:
03/04/2025
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:13 AM
MET WITH: Adi Lina TuilomaTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 03/04/25 at 10:12 AM to conduct an unannounced Plan of Correction (POC) visit. LPA met with care staff Adi Lina Tuiloma and explained the purpose of the visit. The purpose of this visit was to verify the plan of correction that was required to be completed on 02/28/25 for deficiencies that were previously cited on a prior visit conducted on 02/20/25. The current census is 14 with 3 facility staff.

During today's visit, LPA conducted a tour of the facility and tested the signal system with direct care staff Adi Lina. Based on observation a new signal system was purchased and installed and observed to be in good repair. The signal system also emits an auditory signal to the staff central location of the facility. LPA Lee also observed toxins and sharp knifes kept locked and inaccessible to residents in care.


Based upon this inspection, LPA observed the following:

1. The deficiency cited under Title 22 Regulation 87309(a) has been cleared. The license did complied with the terms of the POC-by-POC due date. A POC letter was generated and provided to the licensee.

2. The deficiency cited under Title 22 Regulation 87303(i)(1)(B) has been cleared. The license complied with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee.

As a result of this, POC visit the facility is in compliance with Title 22 Regulation. No other deficiencies were observed or cited during today’s Plan of Correction visit. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE: DATE: 03/04/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/04/2025
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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