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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 03/24/2025
Date Signed: 03/24/2025 01:44:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Pang Lee
PUBLIC
COMPLAINT CONTROL NUMBER: 27-AS-20250225081441
FACILITY NAME:VITA BELLA ELDERLY CARE IIIFACILITY NUMBER:
342701192
ADMINISTRATOR:CLEOPATRA GARDINERFACILITY TYPE:
740
ADDRESS:6700 SUN RIVER DRTELEPHONE:
(916) 490-0237
CITY:SACRAMENTOSTATE: CAZIP CODE:
95828
CAPACITY:14CENSUS: 13DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
12:16 PM
MET WITH:Adi Lina TuilomaTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Staff restrained resident to wheelchair.
INVESTIGATION FINDINGS:
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On 03/24/25, Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with direct care staff Adi Lina Tuiloma and explained the purpose of the visit. Care Staff Adi Lina Tuiloma informed administrator Cleopatra Gardiner that Community Care Licensing Department (CCLD) was present in the facility. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 13 with 3 facility staff. A brief interview with administrator Cleopatra Gardiner was conducted over the telephone to go over the complaint finding.

It was alleged that staff restrained resident to a wheelchair. The investigation involved conducting interviews and reviewing records. In interviews with 2 out of 2 facility staff they admitted that Resident 1 (R1) was restrained to a wheelchair.

Continued LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 27-AS-20250225081441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/24/2025
NARRATIVE
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 During an interview with Staff 1 (S1), S1 explained that R1 had a belt attached to the wheelchair, and S1 would strap R1 into the belt for security reasons. S1 clarified that the belt was not used all the time but would be applied when S1 was not nearby R1. S1 stated S1 used the belt about once or twice. In a separate interview, S2 confirmed that S2 believed the belt was being used and saw something on R1’s waist. However, upon reviewing the R1’s records, it was learned that R1 did not have a written physician's order for the use of the belt nor consent from R1's responsible party.

As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 27-AS-20250225081441
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2025
Section Cited
CCR
87608(a)(3)
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87608(a)(3) Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident…
(3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record...
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Administrator agrees to ensure that a written physician’s order is in place prior to using any postural support. Administrator agrees to review the regulation cited and provide postural support training to all staff and provide
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This requirement was not met as evidence by:

The facility used a belt on R1 without a written physician’s order in place.
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LPA Lee training documents used for the training with staff sign in sheets and statement of acknowledgement of reading and understanding the regulation cite by POC date 03/31/25 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.
SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3