342701192-4-23-2025-27-AS-KHOS-DG7KEZ-20250429075110

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 342701192
Report Date: 04/23/2025
Date Signed: 04/23/2025 09:40:25 AM

Unsubstantiated

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
02/11/2025 and conducted by Evaluator Pang Lee

PUBLIC

COMPLAINT CONTROL NUMBER: 27-AS-20250211104147

FACILITY NAME:	VITA BELLA ELDERLY CARE III		FACILITY NUMBER:	342701192
ADMINISTRATOR:	CLEOPATRA GARDINER		FACILITY TYPE:	740
ADDRESS:	6700 SUN RIVER DR		TELEPHONE:	(916) 490-0237
CITY:	SACRAMENTO	STATE: CA	ZIP CODE:	95828
CAPACITY:	14	CENSUS: 12	DATE:	04/23/2025
		UNANNOUNCED	TIME BEGAN:	08:28 AM
MET WITH:	Lina Tuilona		TIME COMPLETED:	09:31 AM

ALLEGATION(S):

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Facility did not seek medical attention in a timely manner.

INVESTIGATION FINDINGS:

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On 04/23/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care giver Lina Tuilona and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 12. A brief interview with conducted with administrator Cleopatra Gardiner via telephone call.

It was alleged that the facility did not seek medical attention for a resident in a timely manner. The investigation included interviews with facility staff and residents, as well as a review of relevant records. LPA Lee interviewed three staff members, all of whom denied the allegation. The facility staffs stated that Resident 1 (R1) was transported to the emergency room the day after an unwitnessed fall. LPA Lee also interviewed four out of four residents, all of whom expressed no concerns regarding facility staff not seeking medical attention to residents in care

Continued LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 27-AS-20250211104147

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: 04/23/2025

NARRATIVE

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. Resident 2 (R2), who shares a room with R1, reported witnessing R1 fall from R1’s wheelchair on 02/09/25. R2 stated that R2 immediately sought assistance from facility staff 1 (S1), who responded and attended to R1. Despite the fall being unwitnessed by staff, the facility contacted emergency medical services on 02/10/25, and R1 was transported to Kaiser South for evaluation. According to R1’s After Visit Summary from Kaiser, R1 was admitted on 02/10/25 for a fall with a discharge date of 02/12/25. Medical documentation noted: “No acute hemorrhage. No mass effect or herniation. No acute intracranial injury.” The facility’s Plan of Operation outlines that emergency medical services (911) will be summoned immediately if a resident shows sign of distress (e.g., shortness of breath, chest pain, changes in consciousness). For non-serious emergencies, as determined by the administrator or supervisor on duty, the resident will be treated with first aid. In this case, the facility followed protocol and R1 assessed R1 during the fall and R1 was provided medical attention the next day.

The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation us UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.

SUPERVISORS NAME: Czarrina A Camilon-Lee
LICENSING EVALUATOR NAME: Pang Lee
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2025

LIC9099 (FAS) - (06/04)

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