Vita Bella Elderly Care

Type of visit: Case Management - Other

On 7/23/26 at 3:00pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management inspection to obtain documents requested by the department. LPA met with staff member Misi Qadroka and explained the purpose of todays visit. LPA met with staff present, and requested the file for R1 (See confidential names list, LIC 811 dated 7/23/26). LPA requested and obtained a copy of R1's admission agreement which was signed on 5/14/26. Exit interview conducted and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 23, 2026

Allegation investigated: ) The facility allowed excluded individuals to work in the facility. 2) Staff are forging resident documents. 3) The Administrator is not present at the facility for a sufficient amount of

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection at Vita Bella Elderly Care (RCFE) on DATE at TIME to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Sera Nakalevu and together discussed the investigation details. Based on files obtained and reviewed during the investigation process, LPA Gould was unable to corroborate the allegation. LPA reviewed 10 resident files. LPA requested and obtained the admission agreement and physician reports (LIC 602) for all 10 residents in care (see confidential name list LIC-811 dated 7/15/26). LPA Gould reviewed reports for each resident. Upon review, the department has no concerns the physician reports are being altered or fraudulent. All 10 files reviewed appear to be completed by the resident’s physician or an appropriately skilled professional that are able to complete the forms per department regulations. Report Continued on LIC 9099-C Unsubstantiated Additionally, LPA conducted interviews with four staff members and four residents. All staff interviewed denied excluded individuals presence at the facility and had knowledge they are not allowed at any licensed facility. The four residents interviewed denied witnessing any individuals identified in the complaint as being present at the facility or did not recognize photos of the identified individuals. All staff interviewed knows who the administrator is and identified her most recent date working as the previous weekend. Administrator is currently identified as sick this week. All four residents interviewed were able to identify who the facility administrator is and identified her most recent working date as the previous weekend. All residents interviewed identified the administrator present on a regular basis. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Other are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Jul 15, 2026 · control 27-AS-20260211122958

Allegation investigated: Resident is being neglected by facility staff Facility is not ensuring residents gets to doctors appointments Facility does not ensure resident receives medications

On 03/23/2026, Licensing Program Analyst (LPA) Pang Lee arrived unannounced at the facility to conduct a complaint visit. LPA Lee met with Administrator Aliti Waqalala and explained the purpose of the visit. The purpose of the visit was to deliver the complaint finding regarding the above allegation. The facility’s current census is 10. A brief interview was conducted with Administrator Waqalala. Based on interviews conducted with facility staff, as well as a review of records obtained during the investigation, it was learned that Resident 1 (R1) had multiple scheduled medical appointments that were not attended. R1 had an appointment on 06/25/2025 at 2:20 PM; however, according to the Administrator, Aliti, R1 was unable to attend due to transportation not arriving. The appointment was rescheduled to 07/02/2025 at 3:00 PM, but R1 again did not attend due to transportation issues, and the facility did not follow up to reschedule. CONTINUED LIC 9099-C Substantiated An additional appointment on 07/25/2025 was also missed due to transportation issues and a scheduling conflict with R1’s neurologist appointment; no follow-up or rescheduling was conducted by the facility. Furthermore, R1 had an appointment on 08/25/2025, which was missed due to a change in R1’s condition, and no attempt was made by the Administrator Aliti to reschedule. Confirmation from the clinic indicated that there were no completed encounters or rescheduled appointments for these missed visits. Moreover, a review of R1’s external referral form dated 06/19/2025 revealed that R1 had stopped following up with their neurology provider, and now that the office is closed a new referral will be submitted. It was also learned that R1 was hospitalized on 11/06/2025 and discharged on 11/14/2025 with a change in condition, including a special diet of mechanical soft diet. A review of R1’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) revealed that these documents were not updated to reflect R1’s change in condition. Additionally, it was learned that in the days leading up to hospitalization, R1 experienced a rapid and significant decline from baseline, including excessive mucus production resulting in choking episodes during sleep. Despite these symptoms, R1 was not promptly taken to the hospital or referred to a primary care provider, and this change in condition was not documented in facility records until addressed to Administrator Aliti on 01/05/2026. Per the Admission Agreement, the facility is responsible for regularly observing residents’ physical and mental conditions and arranging for incidental medical and dental care services; however, the facility did not meet these obligations. On 01/06/2026, Licensing Program Analysts (LPAs) Lee and Tamayo reviewed medications for three of ten residents by comparing medications on hand with Medication Administration Records (MARs) and identified discrepancies. MARs were not initial on multiple days, making it unclear whether medications were administered as prescribed or if staff did not document administration. Additionally, medications were not consistently administered in accordance with bubble pack instructions regarding dates and times. On 02/03/2026, LPAs Lee and Hughes reviewed Resident 2 (R2)’s MAR and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. A review of R2’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets, and the Centrally Stored Medication Destruction Record (CSMDR), which indicated a start date of 11/05/2025, revealed discrepancies. Care staff Qadroka conducted a pill count and reported ten (10) tablets remaining, indicating inconsistencies in medication tracking. A review of R1’s MARs from October through January also showed discrepancies. CONTINUED LIC 9099-C MAR log for December 2025, shows some medications were documented as administered from 12/25/2025 to 12/27/2025 and some medications indicating that R1 did not get the medication since R1 was hospitalized during that time as well. Overall, the medication audit for R1 revealed multiple inconsistencies. Based on interviews, observations, and records reviewed during the investigation, LPA Lee was able to corroborate the allegations. As a result, these allegations are SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies were cited for two of the allegations: resident is being neglected by facility staff and facility does not ensure resident receives medications during a case management visit on 02/03/2026, therefore the findings are still substantiated and no citation for those two allegations will be given. However, the facility is being cited today for the allegation facility is not ensuring residents gets to doctors’ appointments. Citation is on LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Administrator, Aliti and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility. Moreover, Facility staff acknowledged that the facility did not always maintain the required two-day supply of perishable food and seven-day supply of non-perishable food; however, staff stated that residents were not being deprived of meals. In addition, the facility was cited on 01/06/2026 for insufficient food supplies. During a prior facility visit on 01/05/2026, LPAs Lee and Tamayo toured the facility and observed seven (7) residents seated at the dining table eating breakfast. On 02/03/2026 facility visit, LPAs Lee and Hughes observed seven (7) residents eating breakfast, which included egg omelets, hash browns, toast, strawberries, blueberries, bananas, and coffee. Apples and oranges were also observed on the kitchen counter and available for resident access. Based on interviews and observations conducted during the investigation, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards has not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation is 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 occurred. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Mar 23, 2026 · control 27-AS-20251231102322

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(1) · Plan of correction due date: Mar 30, 2026

87465(a)(1) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by: Based on interview and record review, the licensee did not comply with the section cited above. Resident 1 (R1) had three scheduled medical appointments that were missed, and the facility did not attempt to reschedule any of them. This poses an immediate health, safety or personal rights risk to people in care.the state’s words, verbatim · CDSS document, Mar 23, 2026

Plan of correction: The Administrator agrees that all scheduled resident appointments are completed, and that any missed appointments are promptly rescheduled. The Administrator will also review the cited regulation and provide LPA Lee with a written statement acknowledging understanding of the regulation. (POC) is due by 03/30/2026 at 5:00 PM.

Type of visit: Case Management - Deficiencies

On 2/19/26 at 1:15pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced Case Management deficiencies inspection to address deficiencies observed while conducting a complaint investigation. Upon arrival, LPA observed the sliding gate in front of the facility was closed in a manner that prevents residents from easily opening the sliding gate and preventing residents from leaving the facility property or exiting the property in cases of emergency. LPA Gould also observed bedroom #3's door has windows with no blinds or curtains to provide privacy for the two residents who share the bedroom. Per California Code of Regulations, Title 22, the following deficiencies are cited. An immediate civil penalty was also issued during today's inspection. Exit Interview Conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Feb 19, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Feb 20, 2026

Personal Rights of Residents in All Facilities: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not met as evidenced by LPA observations of the facility gate continuing to be manipulated in a way that prevents the gate from being opened as designed which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: Licensee shall provide a written statement including policies and procedures for staff to ensure the gate is not manipulated in a way that may prevent residents from opening the gate and exiting the facility premises.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.2(a)(1) · Plan of correction due date: Feb 20, 2026

Additional Personal Rights of Residents in Privately Operated Facilities: To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups. This requirement was not met as evidenced by LPA observations of the bedroom door for Bedroom #3 has a window with no coverings and the residents who share the bedroom have no privacy in their bedroom which poses an immediate health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Feb 19, 2026

Plan of correction: licensee shall provide blinds or curtains that can be opened or adjusted from inside the bedroom or replace the door with a solid door and no windows by the POC due date: 2/20/25.

Type of visit: Case Management - Health Checks

Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to conduct a health and safety inspection and a case management visit. The facility is on a quarterly visit due to non-compliance concerns discussed during a Zoom meeting on 11/18/2025. LPAs met with care staff Misivono Qadroka and explained the purpose of the visit. Care staff informed Administrator Aliti Waqalala via text message that Community Care Licensing Division (CCLD) was present at the facility; however, the Administrator did not respond. LPA Lee attempted to contact Administrator Waqalala by phone and left a voicemail. The facility census was nine (9) residents with two (2) staff present. The purpose of today’s visit was to conduct a quarterly inspection. LPAs followed up on the following areas: · Incontinence care: LPAs did not observe or detect any incontinence odors throughout the facility. · Criminal record clearance and staff association requirements: LPAs observed Staff 2 (S2), who is fingerprint-cleared and associated with the facility. · Fire clearance and fire safety: LPAs observed that the front gate was unlocked and easily operable. Exit doors and emergency exits were observed to allow single-action operation, and residents were not locked in or out of the facility. CONTINUED LIC 809-C · Incidental medical and dental care services: LPAs reviewed Resident 1 (R1)’s Medication Administration Record (MAR) and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. LPAs reviewed R1’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets. A review of the Centrally Stored Medication Destruction Record (CSMDR) showed a start date of 11/05/2025. Care staff Qadroka conducted a pill count and reported ten (10) tablets on hand, indicating discrepancies in R1’s medication count. · Food supplies: LPAs observed that the facility had sufficient food supplies, meeting the requirements of a two-day perishable and seven-day non-perishable supply at the time of the visit. · Change in condition assessments and reassessments: LPAs learned that Resident 2 (R2) was sent to the hospital on 10/22/2025 and discharged with a special mechanical-soft diet. A review of R2’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) indicated that the special diet was not updated to reflect this change in condition. · Door alarms and alert systems: LPAs observed door alarms installed on the front door, dining room sliding door, and the back door of Resident Room #3. · Quality of food provided: LPAs observed seven (7) residents seated at the dining table eating breakfast. The meal included egg omelets, hash browns, toast, strawberries, blueberries, bananas, and coffee. LPAs also observed apples and oranges available on the kitchen counter for resident access. · Personal rights: LPAs toured the kitchen and observed that the refrigerator and food cabinets were unlocked, allowing residents access in accordance with personal rights requirements. · Communication and responsiveness with the Department: LPA Lee emailed Administrator Waqalala on 01/29/2025 requesting additional information and documents related to complaint control number 27-AS-20251231102322, with a due date of 01/30/2025. A follow-up request was also sent on 02/01/2026, with no reply from the Administrator. During today’s visit, care staff Qadroka and LPA Lee were unable to reach Administrator Waqalala. As a result, of today's quarterly visit, deficiencies can be found on the 809D page. An exit was conducted, and a copy of the 809 report, 809D pages, was provided to care staff Qadrokathe state’s words, verbatim · CDSS document, Feb 3, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(c)(2) · Plan of correction due date: Feb 17, 2026

87465(c)(2) Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for non-prescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. LPAs reviewed Resident 1 (R1)’s Medication Administration Record (MAR) and observed missing initials for medication administration on 02/01/2026 and 02/02/2026. LPAs reviewed R1’s medication, Amlodipine 10 mg (take one tablet by mouth daily), with a quantity of 30 tablets. A review of the Centrally Stored Medication Destruction Record (CSMDR) showed a start date of 11/05/2025. Care staff Qadroka conducted a pill count and reported ten (10) tablets on hand, indicating discrepancies in R1’s medication count. This poses an immediate health, safety or personal rights risk to people in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: The facility will conduct Incidental Medical training from CCLD approved venders/Pharmacy regarding resident medication administration and maintaining accurate records of MARs and CSMDR. Staff training sign in and documents used for training as well as a statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by 02/17/2026 end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a) · Plan of correction due date: Feb 17, 2026

87463(a) Reappraisals (a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by: Based on observation, interview and record review, the licensee did not comply with the section cited above. LPAs learned that Resident 2 (R2) was sent to the hospital on 10/22/2025 and discharged with a special mechanical-soft diet. A review of R2’s LIC 603A (Resident Appraisal) and LIC 625 (Needs and Services Plan) indicated that the special diet was not updated to reflect this change in condition. This poses a potential health, safety or personal rights risk to people in care.the state’s words, verbatim · CDSS document, Feb 3, 2026

Plan of correction: The facility will conduct Reappraisals/change in condition training. Staff training sign-in and documents used for training as well as a statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by 02/17/2026 at the end of day 5:00 PM. A statement of understanding and acknowledging of the regulation cited will be provided to LPA Lee by 02/17/2026 end of day 5:00 PM.

Type of visit: Required - 1 Year

On 01/06/2026, Licensing Program Analysts (LPAs) Pang Lee and Cynthia Tamayo arrived at the facility to conduct an unannounced annual inspection. LPAs met with Misivono Qadroka and explained the purpose of the visit. LPAs requested that staff notify Administrator Aliti Waqalala of CCLD’s presence. The Administrator’s Certificate number is 7025683740, which expires on 06/16/2027. The facility’s current census is 10 residents, with 2 staff members present. Administrator Waqalala was not present during today’s inspection. The facility is licensed for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents, with an approved hospice waiver for one (1) resident. LPAs inspected the physical plant, including but not limited to the common areas, kitchen, dining area, residents’ bedrooms, residents’ bathrooms, laundry room, staff room, and outdoor courtyards, to ensure compliance with Title 22 regulations. LPAs observed the facility to be clean, free of odors, and not in good repair. Resident bedrooms were properly furnished and equipped with appropriate bedding and lighting. During today’s kitchen inspection, LPAs observed insufficient seven-day non-perishable and two-day perishable food supplies. Care staff Qadroka stated that he put in an order for food delivery yesterday and that the delivery should be delivered today around 2:05 PM to 2:35 PM. During the visit, LPAs did observe groceries being delivered to the facility from Walmart. Additionally, during a complaint control Number # 27-AS-20251231102322 on 01/05/2026, LPAs inspected the facility’s food inventory to determine whether adequate food supplies were maintained on the premises, specifically a minimum of two days of perishable food and seven days of non-perishable food, sufficient for ten residents. CONTINUED LIC 809-C LPAs discussed food supply requirements with Administrator Waqalala, who confirmed that the facility did not have sufficient perishable food supplies to prepare 60 meals for ten residents, nor sufficient non-perishable food supplies to prepare 210 meals. LPA Tamayo observed one resident request seconds; however, no additional breakfast food was available. Staff member S3 offered the residents an apple retrieved from the microwave. S3 stated that the fruit basket was placed in the microwave overnight to clear the counters and to prevent residents from eating fruit at night. S3 agreed to place the fruit basket on the kitchen counter so it would be accessible to residents. Moreover, on 01/05/2026 during a complaint control investigation, LPAs also observed the front gate to be manipulated in a way that prevents residents from easily opening the perimeter gate and exiting the facility grounds. Hot water temperature measured 112.8 degrees Fahrenheit at a resident bathroom sink, which is not within the required range of 105 to 120 degrees Fahrenheit. Smoke detectors and carbon monoxide detectors were observed to be in compliance with fire safety requirements. A fire extinguisher was observed in the kitchen and was last serviced on 01/22/2025. LPAs reminded the facility that the fire extinguisher is due for servicing this month. The last fire drill was conducted on 10/27/2025. LPAs observed a working public telephone located in the kitchen and verified that required postings were displayed. The facility thermostat was observed at 76 degrees Fahrenheit, which is within the required range of 68 to 85 degrees Fahrenheit. LPAs observed toxic substances stored in the kitchen cabinet and kept locked and inaccessible to residents. Sharp knives were observed to be locked in a kitchen cabinet and inaccessible to residents. Medications were observed to be properly stored, locked, and inaccessible to residents; however, during the first aid kit inspection LPAs observed a bottle of over-the-counter pain medication inside the first aid kit made accessible to residents since the first aid kit was not locked. Care staff Qadroka removed the medication and locked it up. The first aid kit was inspected and contained all required components. LPAs observed two broken windows in the courtyard. During a case management on 09/30/2025, LPA Tamayo provided the facility with a Technical Violation requesting that the broken windows be discarded by 10/07/2025; however, the windows have not been removed as it is a safety hazard. During the visit, LPAs observed maintenance Roseindiz taking the broken windows to be thrown away. CONTINUED LIC 809-C LPAs reviewed medications for 3 of 10 residents by comparing medications on hand with the Medication Administration Records (MARs) and observed discrepancies. It was observed that MARs were not initialed for multiple days, making it unclear whether medications were administered as prescribed or whether staff didn’t initial the MARs. Additionally, medications were observed not to be administered in accordance with the bubble pack instructions for days and times for residents. Citations will be issued on complaint control Number # 27-AS-20251231102322. LPAs reviewed 5 of 10 resident files, which were complete. LPAs also reviewed 3 staff files, which were complete. A review of staff criminal record clearances confirmed that all facility staff and required individuals are fingerprint-cleared and associated with the facility. The following documents are to be emailed to LPA Lee by 01/09/2026 by 5:00 PM: 1. LIC 308 – Designation of Administrative Responsibility 2. Copy of Administrator Certificate 3. LIC 610 – Current Emergency Disaster Plan 4. Proof of Current Liability Insurance 5. LIC 500 – Current Personnel Report LPAs reminded the facility that their annual fees are due and that LPA Lee will email Administrator Waqalala the PIN number, which can be used to pay the balance at CCLD website http://www.ccld.ca.gov/. As a result of this annual visit, the facility is not in compliance with Title 22 regulations. Deficiencies are documented on LIC 809-D. An exit interview was conducted with Care staff Qadroka, and copies of LIC 809, LIC 809-D, and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 6, 2026

The state marks this report as 8 pages; the online copy we transcribed has 7. You can request the full file from the county licensing office.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) follow-up was held on November 18, 2025, via Microsoft Teams with the Sacramento South Regional Office. The purpose of this meeting was to follow up on the NCC conducted on January 30, 2025, and its compliance and to address ongoing deficiencies and the facility’s continued inability to maintain substantial compliance with regulations over the past 11 months. Attendees included Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Analysts (LPAs) Pang Lee, Shakaricka Hughes, and Cynthia Tamayo, and Ombudsman Lisa Carrera. Facility representatives included Licensee Mark LaBella, Administrator Marie Taylor, and Administrator Sera Nakalevu. Administrator Aliti N Waqalala, could not attend the meeting. During the meeting, the Non-Compliance Follow-Up process was reviewed with the Licensee and Administrators. A Non-Compliance Follow-Up Meeting Summary (LIC 9111) was completed and provided to the Licensee along with a copy of this report. Since January 30, 2025, NCC, the facility has received 10 Type A citations and 15 Type B citations. Issues discussed included: · Incontinence care · Criminal Record Clearance and staff association requirements CONTINUED LIC 809-C · Fire clearance and fire safety (ensuring all exit doors and all emergency exits operate with a single-action mechanism and that residents are to be not locked within the facility and out of the facility; gates may not be difficult or hinged in a way that restricts exiting/entering) · Reporting requirements · Incidental Medical and Dental Care Services (including proper medication administration and internal medication audits) · Insufficient food supplies (7-day non-perishable and 2-day perishable requirements) · Dementia care, including wandering resident protocols and awake staff requirements · Basic Services (care and supervision) · Change in condition assessments and reassessments · Staff training and staff responsibilities · Door alarms and alert systems · Quality of food being provided · Personal rights (including the requirement that food, pantry items, and refrigerated items not be locked) · Communication and responsiveness with the Department · Oversight expectations when the Administrator is absent, including Licensee oversight, trained staff coverage, and conducting random evening and NOC shift visits/audits CONTINUED LIC 809-C The facility reported the following corrective actions and plans have been put in place: · Deadbolt removed from exit door · Lock removed from pantry · Training conducted on care and supervision · A new call system was purchased two weeks prior · Weekly routine established: full walk-through every Monday; full medication checks every Tuesday to verify new medications are on the MAR and CSDMR · Licensee visits the facility weekly · A stand-up freezer was purchased to increase food storage. · Staff from all three homes are submitting photos of every meal (breakfast, lunch, and dinner) to verify nutritional quality Change of ownership for three facilities was also discussed. Vita Bella Elderly Care and Vita Bella Elderly Care II have pending change-of-ownership applications. Vita Bella Elderly Care III has no pending application at this time. Licensing reported that Vita Bella Elderly Care II is pending fire clearance for sprinklers. Technical Support Program (TSP) engagement was offered and accepted by the Licensee. LPAs will submit the TSP referral, and the Regional Office will extend and increase quarterly monitoring for the next six months to assess the facility’s progress and compliance with issues identified during the NCC meetings on 01/30/2025 and 11/18/2025. The Regional Office will reassess compliance in six months and will initiate the legal process if the facility does is not in compliance. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Nov 18, 2025

Allegation investigated: staff did not assist resident in care

On 10/17/2025, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Administrator Aliti Waqalala 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 10 with 2 facility staff. A brief interview conducted with Administrator Waqalala. It was alleged that staff did not assist residents in care. An investigation was conducted, which included a review of records as well as interviews with staff and residents. It was learned that on 09/27/2025, Resident 1 (R1) was seated on the sofa and attempted to stand. Resident 2 (R2) initially attempted to assist R1, then walked away to inform Staff 1 (S1). At the time, S1 was in the kitchen preparing dinner and needed to turn off the stove before attending to R1. In interviews, both R1 and R2 confirmed that S1 did provide assistance. CONTINUED LIC Unsubstantiated Resident 3 (R3), who observed the situation, stated they were unsure whether staff assisted the situation, as they returned to their room before the interaction was complete. LPA Lee interviewed 6 of 6 residents, all of whom reported that facility staff are responsive and provide assistance when needed. 6 out of 6 residents also stated having seen staff assist R1 with standing and transfer in the past. Three staff members were also interviewed. All denied having witnessed any instances where staff did not assist residents with care. It was also learned during the investigation that R2 is protective of R1 and often attempts to assist R1 directly. Staff have previously redirected R2 to notify staff instead. Based on the interview statements conducted during the investigation process, LPA Lee was unable to corroborate the allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Oct 17, 2025 · control 27-AS-20251002101620

Type of visit: POC

Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 10/17/2025 to conduct an unannounced Plan of Correction (POC) visit. LPA met with Administrator Aliti Waqalala 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 10/08/2025 for deficiencies that were previously cited on a prior visit conducted on 10/07/2025. During today's visit, LPA conducted a brief tour of the facility. The current census was 10 with 2 facility staff. During today’s visit, LPA Lee toured the facility and observed 3 residents in the common area watching television, while 7 residents remained in their rooms in bed. No odors related to incontinence were detected during the visit. A Walmart delivery consisting of 10 bags of groceries and household supplies was observed. Fresh fruits such as pears, bananas, oranges, plums, avocados, and red apples were observed available on the kitchen counter for residents. Additionally, LPA Lee observed a sufficient supply of food, including at least seven days’ worth of non-perishable items and two days’ worth of perishable goods. LPA Lee inspected and observed that the deadbolt on the front door had been removed. The door is now equipped with a single-action lock that can be opened from the inside, in compliance with fire safety regulations. CONTINUED LIC 809 Based upon this inspection, LPA observed the following: I. The deficiency cited under Title 22 Regulation 87203 Fire Safety has been cleared. The license did comply with the terms of the POC-by-POC due date. A POC letter was generated and provided to the licensee. II. The deficiency cited under Title 22 Regulation 87468.1(a)(6) Personal Rights of Residents in All Facilities has been cleared. The license comply 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.the state’s words, verbatim · CDSS document, Oct 17, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/07/2025 to conduct a case management visit. LPA Lee met with Administrator Aliti Waqalala and explained the purpose of the visit. LPA Lee spoke with administrator Waqalala regarding the purpose of today’s visit and the deficiencies observed on 10/07/2025. The purpose of the visit is to follow up on deficiencies learned during complaint investigation control number # 27-AS-20251002101620. Upon arrival, LPA Lee rang the doorbell and observed through the glass window that care staff (S1) attempted to open the door but was unsuccessful. A few seconds later, S1 unlocked the door with a key and allowed LPA Lee to enter. LPA Lee questioned S1 why the front door is locked and S1 explained that the front door is locked at night and had not yet been unlocked for the morning. Based on observation, the facility’s front door is equipped with a reverse lock, which means that when it is locked from the inside with a key, the door cannot be opened to exit the building. During the visit, Administrator Aliti Waqalala was present in the kitchen preparing breakfast for the residents. In an interview, Administrator Waqalala stated that she locks only the front door every night at approximately at 8:00 PM due to a few residents specifically resident 1 and resident 2 (R1 and R2) who leave the facility and wander at night. LPA Lee inquired about why R1 is not allowed to leave independently, especially if R1’s LIC 602 Physician’s Report indicates R1 may leave unassisted. Administrator Waqalala responded that although R1 may be permitted to leave, allowing R1 to do so then R2 also wants to leave the facility as well which could create safety concerns. Additionally, during the visit, a grocery delivery from Walmart was received. CONTINUED LIC 809-C Based on observations and interviews the administrator did not comply with Fire Safety and residents' personal rights requirements by locking the emergency front door at night, which violates California Code of Regulations Section 87203 Fire Safety and 87468.1(a)(6) Personal Rights of Residents in All Facilities The following deficiencies were identified and cited in accordance with the California Code of Regulations, Title 22, and the California Health and Safety Code. Additionally, an immediate civil penalty of $500.00 was accessed on 10/07/2025 and a repeat violation in the amount of $1000 since this violation was also cited on 09/23/2025. The deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, LIC 421IMs and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Oct 7, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Oct 8, 2025

87203 Fire Safety All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by: Based on observations and interviews, it was learned that the administrator did not comply with Fire Safety requirements by locking the emergency front door at night. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator agrees to not lock the door from inside the facility and will reverse the lock to ensure that facility can’t lock from inside the facility. Administrator will also review the regulation cited today and provide LPA Lee a statement of acknowledgement of understanding the regulation. Administrator will provide LPA Lee photos of the lock being revised. POC due 10/08/2025 end of day 5:00 PM

From the deficiency page — Deficiency type: Type A · Section cited: CCR87468.1(a)(6) · Plan of correction due date: Oct 8, 2025

87468.1(a)(6) Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night… This requirement is not met as evidenced by: Based on observations and interviews the administrator did not comply with residents’ personal rights by locking the front door with a key at night so that residents can’t leave the premises.the state’s words, verbatim · CDSS document, Oct 7, 2025

Plan of correction: Administrator agrees to not lock the door from inside the facility and will reverse the lock to ensure that residents who are allowed to leave the premises based on their LIC 602 Physician’s report they are able to leave. Administrator will also review the regulation cited today and provide LPA Lee with a statement of acknowledgement of understanding the regulation. Administrator will provide LPA Lee photos of the lock being revised. POC due 10/08/2025 end of day 5:00 PM

Allegation investigated: Staff do not ensure facility is free of pests Staff does not ensure adequate amounts of food is served to residents in care Staff does not ensure night supervision is provided to residents Staff do not prevent residents from entering other residents rooms Staff did not prevent other staff from consuming residents food Staff do not ensure adequate supervision is provided to residents Staff do not ensure reporting requirements are followed Staff do not ensure meals are properly prepared for residents in care Staff does not ensure residents are accorded personal privacy

On 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to complete and close an investigation into the above allegations. LPA identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA Pang Lee called Licensee, Mark Labella to inform them of the purpose of this visit. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) explained the purpose of this vist.S4 called Licensee in order to review complaint findings with LPA Tamayo but they did not answer. The census was 10. LPA observed 10 residents and 2 staff. Based on observations, record review, and interviews, the allegations listed above are SUBSTSANTIATED. It was alleged that staff did not ensure that staff do not ensure facility is free of pests. Ombudsman (O1) observed live cockroaches on 8/28/25. Continued on 9099-C Substantiated It was alleged staff do not ensure medications are dispensed as prescribed. LPA reviewed medications and MARS and did not observe a preponderance of evidence that medications were not dispensed as prescribed. It was alleged staff did not ensure facility had a working water supply for residents in care. LPA observed there was working water supply in kitchen and both bathrooms. The facility provides drinking water via refrigerator water dispenser and sometimes provides bottled water. Based on observations and interviews the allegation that the facility does not have a working water supply for residents in care is unsubstantiated. It was alleged staff does not ensure bathrooms are kept in clean sanitary conditions. Based on observations, the bathroom was in clean condition. LPA observed staff cleaning the bathroom upon arrival on 9/4/2025. It was alleged staff do not ensure bathrooms are in good repair. Based on observations, the bathroom was in working conditions including the toilet, sink faucet, shower, and doors. There was no corroborating evidence to prove staff do not ensure bathrooms are in good repair. It was alleged staff has inappropriate personal conversations while in front of residents. Based on resident and staff interviews there was not a preponderance of evidence that staff has inappropriate personal conversations while in front of residents. It was alleged staff do not seek medical care for residents in a timely manner. Based on records review and interviews, there was no evidence to corroborate that staff do not seek medical care for residents in a timely manner. It was alleged staff discourage residents from filing complaints. Based on records review and interviews, there was no evidence to corroborate that staff discourage residents from filing complaints. It was alleged staff do not ensure adequate supervision is provided to residents. LPA observed two staff during each visit. Based on records review and interviews, there was no evidence to corroborate that staff did not ensure adequate supervision is provided to residents Based on the information gathered through observation and record reviewed, the preponderance of evidence requirement was not met, therefore the above allegations noted were UNSUBSTANTIATED. An exit interview was conducted with S4 and a copy of these LIC 809 reports were provided to the facility. LPA observed a live cockroach in the kitchen counter top when reviewing records. LPA observed cockroach traps in bedrooms, bathrooms, and kitchen areas. Staff and resident interviews confirm there are cockroaches in bathrooms and bedrooms which come out at night. Based on the observations of the LPA and review of resident records the allegation the allegation that do not ensure facility is free of pests is substantiated. On 9/30/25 LPAs observed cockroach on the floor located in the dining room. On 9/23/25, LPA Kevin Gould cited deficiency for regulation 87303(a) during a case management visit, in which the facility has agreed to provide a written cleaning and infection control schedule and provide a written plan of correction indicating how the facility will ensure the facility is kept clean. It was alleged that staff did not ensure that staff does not ensure adequate amounts of food is served to residents in care. LPA toured the kitchen pantry, refrigerator, and freezer inventory and observed. LPA observed there was not sufficient seven day non-perishable and two day perishable food supplies accounting for ten resident’s three meals a day along with utriculus snacks during this visit, on 8/28/25, and 9/4/2025. LPA observed there is no pre-planned menu available to resident’s. The posted sample menu is not followed. LPA observed grocery food deliveries were made on 8/22/25, 8/28/25, 9/4/25, and 9/8/2025, all dates in which Licensing staff and or Ombudsman conducted facility visits. Staff and resident’s stated they think there is not enough food at the facility. Staff stated they did not make dinner on 9/3/25 due to resident ordering and picking up three large pizzas for dinner which they paid for using their personal CalFresh benefits ($53.17) which was given to all residents. The facility Plan of operation states “Menus will offer a variety of dishes, taking into account the cultural and religious background and food habits of the residents … Menus are kept on file in the facility as served … The following menus represent appropriate food groups and portions for our residents … discussion with our residents, this menu may be revised to reflect their individual needs and desires while maintaining a balanced and nutritious diet. At all meals, or anytime, beverages are encouraged and available…”. Based on the observations of the LPA and review of records the staff the allegation that staff do not ensure facility is free of pests is substantiated. On 9/23/25, LPA Kevin Gould cited a deficiency for regulation 87555(b)(26) due to the facility does not have a 2 day perishable food supply to meet the needs of residents which poses an immediate health, safety and personal rights risk to residents in care. It was alleged that staff does not ensure night supervision is provided to residents. Staff stated there is no wake staff and they are upstairs at night time. Four residents stated R5 wonders around at night. Although R5’s appraisal indicated they do not require nighttime supervision, R5’s LIC 602 physicians report indicated they has is dementia diagnosis, "confused and disoriented sun downing behavior and is at risk"; R5’s LIC 602 is was completed over 12 months ago and is in need of a re-evaluation. Continued on 809-C Based on the observations of the LPA and review of records the staff allegation that does not ensure night supervision is provided to resident is substantiated. It was alleged that staff do not prevent residents from entering other residents’ rooms. 5 of 10 residents stated R5 goes into other resident bedrooms. On 9/4/25 and 9/8/25, LPA observed R5 going into other resident bedrooms without knocking first. LPA did not observe any redirection from staff. Based on the observations of the LPA and review of resident records the allegation that Staff do not prevent residents from entering other residents rooms is substantiated. It was alleged that staff do not ensure reporting requirements are followed. Per record review and interviews, the facility did not submit incident reports (SIR) to the regional office for hospitalization that occurred for R4 on 7/11/25 and 9/1/25 and R3 on 8/29/25. Staff stated they informed R4’s family regarding their high blood pressure and emergency hospital transport being called on 9/1/25 but did not have information regarding the other dates. Based on the observations of the LPA and review of resident records the allegation that Staff do not ensure reporting requirements are followed is substantiated. It was alleged that staff do not ensure meals are properly prepared for residents in care. 5 out of 10 residents stated there is not enough food and the quality of food is low as of the last 1-2 months. Record review indicates there are special diets that staff is not aware of. Staff stated Menu’s are not created in advance and are decided based on food inventory the day of or the day before. LPA did not see enough food or vegetables available on 9/4/25 and 9/8/25. LPA observed some breads were burnt and served to residents on 9/4/25. On 9/8/25, LPA observed an egg carton containing 60 eggs with a label that read “keep refrigerated” were being stored in room temp pantry. The egg carted was purchased on 9/4/25 from Walmart. Record review shows there has not been any training regarding food preparation for S1, S2, and S4. Based on the observations of the LPA and review of resident records the allegation staff do not ensure meals are properly prepared for residents in care is substantiated. It was alleged that staff does not ensure residents are accorded personal privacy. 4 out of 10 resents stated R5 opens their door with out knocking often. LPA observed R5 opening the door to R4’s bedroom on 9/4/25. Based on the observations of the LPA and review of resident records the allegation that Staff does not ensure residents are accorded personal privacy is substantiated. continued on 809-C It was alleged that staff did not prevent other staff from consuming residents food. S1 admitted they and S2 each ate two slices from the food a resident purchased on 9/3/25 with their personal funds. Based on the observations of the LPA and review of resident records the allegation that staff did not prevent other staff from consuming residents food. is substantiated. Based on the information gathered through observation and record reviewed, the preponderance of evidence was met, therefore the above allegations noted were SUBSTSANTIATED. deficiencies were cited (See LIC809D reports). An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility. An exit interview was conducted with S4.the state’s words, verbatim · CDSS document, Sep 30, 2025 · control 27-AS-20250818095041

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Oct 10, 2025

87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency ...(1) A written report shall be submitted to the licensing agency and to the person responsible... within seven days of the occurrence of ... in (A) through (D). This requirement was not met as evidenced by staff do not ensure reporting requirements are followed. Record review and interviews timely reporting was not completed when residents have gone to the hospital or emergency care was neededthe state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will submit a statement of review and understanding of 87211 Reporting Requirements (a) along with providing training for staff regrading reporting requirements by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(1) · Plan of correction due date: Oct 10, 2025

87555 General Food Service Requirements .(b) The following food service requirements shall apply... (1) ... at least three meals per day... (15) hours shall elapse between the third and first meal. Staff do not ensure meals are properly prepared for residents in care, as no dinner was prepared on ___ .LPA observed there was not enough food supplies for ten residents in care on 8/22/25,9/4/25,9/8/25, and 9/23/25.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will review regulation 87555 and create a menu and set meal times along with staff and resident input accounting for preferences and special dietary needs by POC due date. The Facility will also submit written plan on training staff on meal preparation by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87705(b)(2) · Plan of correction due date: Oct 10, 2025

87705 Care of Persons with Dementia (b) Licensees shall ... (2) ... ensuring there is at least one night staff person awake and on duty if any resident with dementia is determined through... observation to require awake night supervision. .. This requirement was not met as evidenced by staff interviews and record reviews that show there no wake staff at night time and residents with dementia wondering around the facility during day and night time hours, which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will submit statement of review and understanding of 87705(b)(2) along with a written plan of correction to ensure one night staff person awake and on duty by POC due date. Training on supervision and dementia will be provided to all current and new staff within the next three weeks and verification will be submitted to licensing once training is completed.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 7468.1(a)(2) · Plan of correction due date: Oct 10, 2025

7468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights... (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment This requirement was not met as evidenced by interviewees that reveal that staff consumed residents foods. Staff stated resident, Michelle Fine, purchased three large pizzas on 9/3/25, in which residents and staff had for dinner. Staff admitted no dinner was prepared for residents on 9/3/25, this poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will submit a statement of review and understand of 7468.1(a)(2) by POC due date Facility will also reimburse resident for food items purchased in which other residents and staff ate by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.2(a)(1) · Plan of correction due date: Oct 10, 2025

87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents... shall have all of the following personal rights:(1) To have a reasonable level of Personal privacy in accommodations... This requirement was not met as evidenced by LPA observations of residents opening other residents room doors without knocking/permission to do so which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will provide a written declaration that no facility staff will be trained on care and supervision to ensure residents to not enter other private resident rooms.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 10, 2025

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by staff not preventing residents from entering other residents rooms which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility staff will be trained on care and supervision including redirecting residents with wondering behaviors.

Type of visit: Case Management - Deficiencies

On 9/30/25, Licensing Program Analysts (LPAs) Cynthia Tamayo and Pang Lee made an unannounced visit to this facility to follow up on a case management deficiency from a previous complaint visit and quarterly visit, and POC follow up. LPA's identified themselves upon arrival, stated the purpose of the visit, and asked to meet with the administrator Alita Waqalala (S3) but they were not available. LPA's requested to speak with Licensee and S4 contacted them. LPAs met with Staff Merelisoni Mataitoga (S4) and Nawavoli Ratusione (S4) and explained the purpose of this visit. The purpose of this visit was to conduct a quarterly visit to follow up on items outlined during the Non-compliance meeting held on 01/30/2025, which included the requirement for increased monitoring and to follow-up on areas of concern originally identified during the meeting as below. · Basic Services (care/supervision/elopement) · Administrator qualifications/duties and accountability/new potential administrator · Reporting requirements · Incidental Medical and Dental Care Services (resident not receiving medication as prescribed) · Fire clearance (adhering to fire clearance/submitted facility sketch) · Limitations capacity and ambulatory status (non-ambulatory resident cannot reside in an ambulatory room) · Plan of corrections (POCs) submitted in a timely manner Continued on 809-C · Background/fingerprint clearance (volunteers) This visit is also to follow-up on POC that was due to the department on 09/24/2025. This facility is licensed as a Residential Care Facility for the Elderly and is approved to serve a maximum of 10 residents. This facility is approved for 2 ambulatory residents in bedroom #5 only and 8 non-ambulatory residents. During the visit, LPAs conducted an inspection of the physical plant, including but not limited to the common areas, kitchen, dining area, resident bedrooms, bathrooms, laundry room, and outdoor courtyards. The facility was observed to be clean and in good repair and not free of odor. LPAs observed that the previously broken windows had been repaired and were in good condition. The exit gate was also observed to be functioning properly, with a one-way mechanism that does not prevent residents from exiting the facility. In resident bedroom #2, LPAs observed that the room was unoccupied and had a noticeable incontinence odor. On resident bed B, LPAs observed that an incontinence pad with visible urine had not been disposed of. According to Staff #1, the room had not been cleaned all day, as they believed it was locked. All residents bedrooms were properly furnished with appropriate bedding and adequate lighting. The layout of the facility was consistent with the original facility sketch that had been approved during the licensure process. In the resident bathroom, the hot water temperature was measured at 105.8 degrees Fahrenheit, which falls within the required regulatory range of 105 to 120 degrees Fahrenheit. Smoke and carbon monoxide detectors were tested and found to be functioning and in compliance with fire safety regulations. The fire extinguisher was located in the kitchen and had last been serviced on 01/22/2025. LPA also observed that the facility had a public telephone located in the common area. The thermostat was functioning properly and registered at 69 degrees Fahrenheit at the time of inspection. Toxic cleaning supplies were observed to be stored in storage cabinet and securely locked and inaccessible to residents. Sharp kitchen knives were locked in kitchen cabinets and were not accessible to residents. The medication storage area was reviewed and found to be locked and secure. All records reviewed were found to be complete and accurate. The first aid kit was checked and contained all required supplies. LPAs also verified the food supply, confirming that the facility maintained at least a two day supply of perishable food items and a seven-day supply of nonperishable items, in accordance with Title 22 regulations. LPAs observed a new freezer was placed in the kitchen to store additional food. Both residents’ and staff files were reviewed during the visit and were found to contain all required documentation. It is noted that on January 30, 2025, during a non-compliance meeting, the Licensee, Mark Labella, declined the referral to participate in the Technical Support Program (TSP). Despite the program being recommended as a resource to support compliance, the Licensee refused the referral at that time. The recommendation for TSP participation was reiterated; however, the Licensee again declined to participate. Continued 809-C During today’s visit, LPAs also followed up on the prior deficiencies and plan of corrections that were due on 09/24/2025 from a prior case management visit conducted on 09/23/2025. Based upon this inspection, LPAs observed the following: 1. The deficiency cited under Title 22 Regulation 87303(a) has been cleared. The license did comply 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 87555(b)(26) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. 3. The deficiency cited under Title 22 Regulation 87468.1(a)(6) has been cleared. The license comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. The following deficiencies were observe by LPA Tamayo: On 8/28/25, 9/4/25, and 9/8/25 food items in the pantry were locked with a magnetic lock, staff immediately unlocked on 9/8/2025. On 9/30/25, the lock mechanism was not activated but has not been installed. On 8/28/25, 9/4/25, and 9/8/25, eggs were stored in the pantry area however they should be refrigerated as indicated in the box. Staff immediately disposed on eggs and placed an order for fresh eggs. On 9/4/25, LPA Tamayo observed the MARS was not completed from 8/31/25-9/4/25. staff and resident interviewees confirm medications were given, however not documented accordingly. LPA's talked to staff regrading disposing of spare windows and broken chairs in the backyard area. As a result of this case management visit the facility is not in full compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809-D page. An exit interview was conducted with S4 and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 30, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Oct 10, 2025

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by: Based on observation and records review the licensee/admin did not comply with the section cited above. 1 of 1 residents on 8/31/2025 and for 10 of 10 of the resident's medications in the Medication Administration Records from 9/1/2025- 9/4/2025 were not recorded and given per physician's orders according the facility's Plan of Operation which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility staff will conduct daily audits of the centrally stored medications and MAR for the next days and weekly audits thereafter for 30 days with proof of audit logs submitted to Licensing once after the initial days and again after 30 days. Facility to submit an audit plan to Licensing via email by 10/7/2025 at 5:00 pm PST.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87468.1 · Plan of correction due date: Oct 10, 2025

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. Based on observation and records review the licensee/admin did not comply with the section cited above in which the pantry closet has a locking mechanism which poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Facility will submit agreement to not lock food from residents in compliance with regulation 87468 by POC due date. Facility will remove lock mechanism from food storage areas such as the pantry

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87625(b)(3) · Plan of correction due date: Oct 10, 2025

87625(b)(3) Managed Incontinence (b) In addition to Section 87611, General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence. This requirement is not met as evidenced by: In resident bedroom #2, LPAs observed that the room was unoccupied and had a noticeable incontinence odor. On resident bed B, LPAs observed that an incontinence pad with visible urine had not been disposed of. According to Staff #1, the room had not been cleaned all day, as they believed it was locked. which poses an immediate health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Sep 30, 2025

Plan of correction: Administrator agrees to conduct training on managed incontinent care protocols, emphasizing the importance of timely changing of incontinence products and maintaining cleanliness to prevent odors. Training materials used and staff sign in sheets along with statement of acknowledgement of understanding the regulation cited will be provided to LPAs by POC date 10/10/2025. As a result of this case management 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.

Type of visit: Case Management - Deficiencies

On 9/23/25 at 3:15pm, Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced case management deficiencies inspection to address deficiencies observed during today's inspection. LPA conducted a walk through of the facility upon arrival. LPA noted several mice/insect traps around the facility and kitchen. LPA inspected the kitchen cabinets and drawers and observed an abundance of evidence of insect infestation/feces. All kitchen cabinets and drawers are in need or cleaning. LPA observed the facility floors to be dirty and in need of routine cleaning. The facility is not clean sanitary or good repair at the time of inspection. LPA also observed the front windows on each side of the front door are in need of replacement as they do not fit the current window frame and have exposed glass edges that poses a danger to residents, staff and visitors. LPA Gould inspected the food supply and observed the facility has an insufficient supply of food items available for resident use. the facility ran out of milk and residents provided statements that they went to purchase milk from the store. LPA observed a food order from walmart that LPA identified was ordered after LPA's arrival to the facility. LPA determined the food present does not meet the two day perishable requirement per regulations. LPA also observed the front gate to be manipulated in a way that prevents residents from easily opening the perimeter gate and exiting the facility grounds. The following deficiencies are cited per California Code of Regulations Title 22. Exit interview conducted an a copy of this report and appeal rights are left at the facility.the state’s words, verbatim · CDSS document, Sep 23, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Sep 24, 2025

Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by LPA observations of insects/insect feces in every kitchen cabinet drawer, windows in need of repair that do not fit the window frame and have exposed glass edges, and floors in need of routine cleaning which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: facility has agreed to provide a written cleaning and infection control schedule and provide a written plan of correction indicating how the facility will ensure the facility is kept clean. Additionally, the window will be repaired replaced so it no longer poses a danger to residents in care.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87555(b)(26) · Plan of correction due date: Sep 24, 2025

General Food Service Requirements: Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirements was not met as evidenced by LPA observation that the facility does not have a 2 day perishable food supply to meet the needs of residents which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Facility will provide a written plan of correction on the specific steps the facility will take to ensure the facility maintains an adequate supply of perishable foods to meet the needs of residents. LPA observed facility has ordered additional food items to be delivered today. LPA requests copies of all food receipts be sent to the department for the next 2 months.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(6) · Plan of correction due date: Sep 24, 2025

Personal Rights of Residents in All Facilities: To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement was not met as evidenced by LPA observations the facility gate was manipulated in a way to prevent residents from opening the sliding gate at the driveway and preventing them from leaving the facility. which poses an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2025

Plan of correction: Facility will provide a written declaration that no facility staff member will close or manipulate the gate in a way the prevents residents from leaving the facility property.

Type of visit: POC

On 9/8/25, Licensing Program Analyst (LPA) Cynthia Tamayo made a case management plan of correction follow up and deficiency visit. LPA identified themselves upon arrival, stated the purpose of the visit. LPA asked to meet with the administrator Alita Waqalala (S3) but was told they were out sick. LPA called S3 via phone and left a voimail and email requesting a call back. LPA met with Misivono Qadroka (S1). LPA toured the facility, including resident bedrooms, bathrooms, upstairs staff room, common areas, and backyard. LPA observed the following deficiencies during this visit: LPA reviewed staff roster and observed S2 and S4 are associated to the facility. POC letter generated and provided to the facility. LPA did not received a completed staff file for new staff by POC due date of 9/5/25. Facility will receive civil penalty due to failure to correct. There were two staff, S2 and S4. S4. S4 has a cleared criminal background clearance. S4 stated they started working at the facility on 9/6/25. S3 faxed over S4's file to the facility. Upon record review, there is not a complete staff record for S4 either. Exit interview conducted and a copy of this report and appeal rights were left at the facility. LPA observed deficiencies and the facility is not in compliance with Title 22 Regulation, a civil penalty for failure to correct and LPA return to complete a follow up case management. An exit interview was conducted with S1 and a copy of these LIC 809 reports 421FC, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Sep 8, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87412(a) · Plan of correction due date: Sep 10, 2025

87412Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidenced by two staff not having a file to review which includes training information, TB test clearance verifications, and other required documents. This poses an potential or immidiate threat to the Health, Personal Rights, and/ot Safety onto residents in care.the state’s words, verbatim · CDSS document, Sep 8, 2025

Plan of correction: Facility did not complete plan of correction by POC due date. Administrator/Licensee will review regulation 87412 Personnel Records and submit a verification of review and understanding to the deparmtent by POC due date. Administrator will ensure there is a completed staff file by the date of hire.

Type of visit: Case Management - Deficiencies

On 9/4/25, Licensing Program Analyst (LPA) Cynthia Tamayo made a case management deficiency visit. LPA identified herself upon arrival, stated the purpose of the visit was to continue a complaint investigation. LPA asked to meet with the administrator Alita Waqalala (S3) but was told they are off today. LPA spoke with administrator and a brief meeting followed. LPA met with Misivono Qadroka (S1) One out of ten resident residing at the facility was out visit family during this visit. There were two staff members working during this visit. LPAs obtained a posted staff roster dated 9/2024 that is not up to date. LPAs observed there was one staff (S2) member not listed on the schedule and whom was not associated to the facility during this visit. S1 and S2 reported they stated working at the facility on 8/31/25. There are no staff records for S1 and S2. Per California code of Regulations, Title 22, the following deficiency is cited. An immediate civil penalty was issued during today's inspection. Exit interview conducted and a copy of this report and appeal rights were left at the facility.the state’s words, verbatim · CDSS document, Sep 4, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(3) · Plan of correction due date: Sep 5, 2025

87355 Criminal Record Clearance (e) All individuals subject to a criminal record ....shall prior to working, residing or volunteering in a licensed facility... (3) Request a transfer of a criminal record clearance ... This requirement was not met as evidenced by one staff member not being associated to the facility. This poses an immediate threat to the Health, Personal Rights, and/or Safety unto all residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Licensee will associate S2 to the facility via Guardian by POC due date . Facility will associate all staff before they start employment.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87412(a) · Plan of correction due date: Sep 5, 2025

87412Personnel Records (a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. This requirement was not met as evidenced by two staff not having a file to review which includes training information, TB test clearance verifications, and other required documents. This poses an potential or immidiate threat to the Health, Personal Rights, and/ot Safety onto residents in care.the state’s words, verbatim · CDSS document, Sep 4, 2025

Plan of correction: Licensee/Facility will review regulation 87412 Personnel Records and submit a verification of review and understanding to the deparmtent by POC due date. Licensee will ensure there is a completed staff file by the date of hire.

Type of visit: Case Management - Other

On 8/28/2025 at 1:40 PM Licensing Program Analyst LPA's Shakaricka Hughes and Pang Lee arrived at the facility to conduct a case management visit to the facility to deliver an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA's met with facility staff Meli and explained the purpose of today's visit. LPA Hughes handed the Order to Licensee/Facility of Immediate Exclusion from Facility letter to the facility staff and explained that facility staff (S1), if present in the facility needed to leave immediately. Facility staff (S1) is to be removed from all shifts and disassociated from the facility in Guardian. An exit interview was held with Meli and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Case Management - Health Checks

On 06/02/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a health and safety case management visit. The facility is on quarterly visit due to non-compliance concerns discussed during a Microsoft team meeting on 01/30/25. LPA Lee met with administrator Aliti Wagalala and explained the purpose of the visit. The census is 9 with 2 facility staff. LPA Lee and administrator toured the physical plant to ensure compliance with Title 22 regulations. LPA Lee observed 5 resident bedrooms, 2 resident bathrooms, common area, staff room, kitchen, laundry room and the courtyard. LPA Lee observed resident bedrooms to have necessary furniture and furnishings. Bedrooms were equipped with a bed, chair, dresser, and closet space. Bathrooms handrails and non-skid mats are in good repair. Fire extinguishers were up to date and fully charge. No emergency exits were obstructed. LPA Lee reviewed food supply to ensure that the facility had a 2-day perishable and 7-day nonperishable food supply. LPA observed laundry room where it was observed that detergent, laundry room and all cleaning supplies were locked and made inaccessible at this time. Knives were observed to be locked and made inaccessible. LPA requested to review 6 resident files and 3 out of 6 file was incomplete. Resident 1 (R1) was missing LIC 625 Needs and Services, Admission Agreement and LIC 613 Personal Rights. R2’s LIC 601 Emergency and Identification form is incomplete. R3 is missing LIC 601 Identification and Emergency, LIC 625 Needs and Services and LIC 603 Resident appraisal. LPA reviewed staff files and it was observed to be current with up to date. LPA Lee reviewed 3 resident medications, and it was accurate and complete. As a result of this case management visit, the facility is not in compliance with Title 22 Regulation, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with administrator Aliti and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jun 2, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87506(a) · Plan of correction due date: Jun 13, 2025

87506 Resident Records (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff This requirement is not met as evidenced by: Based on observation and records review by this LPA, the licensee did not comply with the section cited above. LPA Lee observed 3 out of 6 resident’s files incomplete which posed a potential health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Jun 2, 2025

Plan of correction: Administrator will ensure that resident’s file is current, accurate and complete at all times. Administrator will complete the incomplete documents observed and email LPA Lee the updated and completed documents for R1, R2 and R3. A statement of correction will be completed and submitted into LPA Lee. POC due by 06/13/25 end of day 5:00 PM.

Type of visit: Case Management - Legal/Non-compliance

A Non-Compliance Conference (NCC) was conducted today on January 30, 2025, via Microsoft Teams with the Sacramento South Regional Office. The purpose of this Non-Compliance Conference meeting to discuss compliance issues at the facility and the steps the facility is taking to address the Departments’ concerns. Present in the meeting is Regional Manager (RM) Stephenie Doub, Licensing Program Manager (LPM) Czarrina Camilon-Lee, Licensing Program Manager (LPM) Stephen Richardson, Licensing Program Analysts (LPA) Pang Lee, Licensee Mark Labella, Administrator Cleopatra Gardiner, Staff Marie Ann Taylor, and Staff Aliti Wagalala. During this virtual meeting, the Non-Compliance Conference process was explained to the Licensee. A Non-Compliance Conference Summary (LIC 9111) was generated to document this office meeting. A copy of this report and the LIC 9111 was provided to the licensee. The facility has previously received 23 Type A citations and 3 Type B citations since 04/14/2021. Issues discussed during the meeting were: · Basic Services (care/supervision/elopement) · Administrator qualifications/duties and accountability/new potential administrator · Reporting requirements · Incidental Medical and Dental Care Services (resident not receiving medication as prescribed) · Fire clearance (adhering to fire clearance/submitted facility sketch) · Limitations capacity and ambulatory status (non-ambulatory resident cannot reside in an ambulatory room) · Plan of corrections (POCs) submitted in a timely manner. · Background/fingerprint clearance (volunteers) · Maintenance and building (self-latch and close gate) · Increased training for incidental medical and dental care (ensuring residents are given medications as prescribed) · Increased training for storage space (cleaning supplies/toxin needs to be inaccessible to residents) · Resident assessment prior to admission and appraisals based on residents change of conditions. The facility has stated they will agree to do the following: · Licensee agrees to put a plan in place for a self-latch/close gate by 02/06/25. · Licensee agrees to conduct incidental reporting training to all facility staff and provide CCLD training materials used for the training and training sign in sheets. Training will be conducted every 6 months. · Licensee agrees to conduct incidental medical training to all facility staff and provide CCLD training materials used for training and training sign in sheets. Training will be conducted every 6 months. · Licensee agrees to submit an addendum for volunteers in the facility. Notwithstanding the above statement, the Department will take the following actions: · The facility will continue to have additional monitoring and facility inspections to verify improvement in compliance. · Licensee stated that he will be meeting up next week with his administrator and potential administrators to discuss TSP and will reach out to LPA. Failure to maintain substantial compliance outlined on the LIC 809 reported dated 04/23/2024 will result in the Licensee/Facility being referred to the Legal Department for review and possible Administrative Action. The RO will revisit compliance in 9-12 months and begin the legal process if the facility is not in compliance. An exit interview was conducted, and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Jan 30, 2025

Type of visit: Required - 1 Year

On 01/28/25 at 8:33 AM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff Aliti Waqalala and Adilina Tuiloma and explained the purpose of the visit. Facility staff called administrator Mark Labella to informed that CCLD is present. A brief interview was conducted with administrator via telephone. Administrator was not present today and caregivers Alita and Adilina assisted with today’s inspection. Administrator certificate # is 7036077740 and will expire on 07/29/26. The current census is 6 with 2 facility staff. This facility is a two-story building licensed to serve eight (8) non-ambulatory residents and two (2) ambulatory residents in bedroom #5 only. The facility is also approved for 1 hospice resident. 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. Hot water temperature was measured at 105.6 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. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 01/22/25. The last fire drill was conducted on 11/19/24. LPA observed the facility has a has a public telephone in the kitchen and the facility has the required posters posted. Facility thermostat observed at 69 degrees Fahrenheit. Continued LIC 809-C LPA observed toxins located in cabinet sink and kept locked and inaccessible to residents. LPA observed sharp knives kept locked and inaccessible to residents. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed and compared 3 out of 6 medication administration record (MAR) and it was complete. The first aid kit was checked and contained all of the required components. LPA requested and staff files for review. LPA reviewed 5 out of 6 resident files and 3 staff files and they were complete. LPA Lee 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 were given to LPA during today's visit. (1) LIC 308 Designation of Administrative Responsibility (2) Copy of Administrator Certificate The following documents will be email to LPA Lee by (1) Current LIC 610 Emergency Disaster Plan (2) Proof of Current Liability Insurance (3) Current LIC 500 Personnel Report Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. An exit interview was conducted, and a copy of this report and LIC 9102 Technical Assistant was provided.the state’s words, verbatim · CDSS document, Jan 28, 2025

Type of visit: Case Management - Other

On 11/20/2024, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a case management visit. LPA were met by caregiver Aliti Waqalala and explained the purpose of this visit. The census is 8. A brief interview was conducted with administrator Mark Labella via telephone. During today's visit administrator was not present. The purposed of today's visit is deliver the Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately. No citations were issued on today's date. A copy of this report and exclusion letter was provided to the facility care staff Aliti Waqalala at the end of this visit.the state’s words, verbatim · CDSS document, Nov 21, 2024

Type of visit: Case Management - Deficiencies

On 09/17/24 at 9:57 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to conduct a case management visit regarding an Absent Without Leave (AWOL) incident which occurred on 09/14/2024. LPA Lee met with care staff Nina Tuiloma who then called the designated staff, Diana Garcia to informed that Community Care Licensing Department (CCLD) is present in the facility. LPA Lee explained the purpose of the visit. The census is 9 with 2 facility staff. At 10:33 AM, LPA Lee toured the facility with care staff Nina, to ensure the safety of the residents. During the tour it was observed that the front door alarm is not in good repair. It is unclear if the alarm is broken or needing a new battery. LPA interviewed designated staff Diana and reviewed incident report dated 09/14/2024. Based on interview and record review, LPA Lee was informed that R1 switched off the front door alarm and left the facility unsupervised. Moreover, the administrator received a call from the resident’s family member informing that (R1) had been found and taken to Kaiser South. Based on (R1)'s LIC 602, Physician Report dated 09/12/2024 (R1) is unable to leave the facility without supervision. It was also learned that the facility staff was not aware that (R1) had left the facility until the family called and informed the administrator that the residents is at the hospital. Based on today's case management, a citation is issued under Title 22, Division 6. An immediate civil penalty in the amount of $1000 is issued in addition to citation due to absence of supervision. An exit interview was conducted with care staff Nina. A copy of this report LIC 809, LIC 809-D, LIC 421 IM and appeal rights was provided to care staff Nina at the end of the visit.the state’s words, verbatim · CDSS document, Sep 17, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 1569.312(a) · Plan of correction due date: Sep 23, 2024

1569.312(a) Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement is not met as evidenced by: Based on interviews and records review, the facility did not comply with section cited above when (R1) AWOL'D from facility. The LIC 602 states the resident is not allowed to leave the facility unassisted. This posed an immediate health and safety risk to the resident in care.the state’s words, verbatim · CDSS document, Sep 17, 2024

Plan of correction: The facility shall conduct an in-service training on basic services with staff to go over what and how staff shall ensure that residents do not AWOL. Administrator shall send the in-service training with materials used for the training on how staff will ensure residents do not AWOL and a signature sheet of all staff who attended. A statement of correction and acknowledgement of the regulation cited and will also be complete and submit to LPA Lee. The Administrator shall email the date of the in-service training, materials used to train staff, plans to ensure resident do not AWOL and statement of acknowledgement to LPA by POC date 09/23/2024 end of day 5:00 PM

Allegation investigated: Resident sustained unexplained injury while in care.

On 08/12/2024 at 10:10 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with caregiver Adi Lina Tuiloma and Aliti Waqalala 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 8 with 2 facility staff. LPA Lee called administrator Mark Labella and left a message. A brief interview was conducted with designated staff Theodore Slypher via telephone. During today’s visit administrator Mark Labella was not present. Allegation: Resident sustained unexplained injury while in care. It was alleged that resident sustained unexplained injury while in care. This investigation consisted of records reviewed, interviews with staff, residents and an outside agency. Throughout the course of the investigation, it was learned that resident 1 (R1) was admitted to the facility on 05/31/2024 with existing rash condition on (R1)’s back. Continued LIC 9099-C Unsubstantiated On 06/02/2024 (S1) took photos of (R1)’s back and had concerned and sent those pictures to the Licensee/Administrator. It was also learned that (R1) came to the facility with home health nurse. LPA Lee reviewed (R1)’s Care Daily Checklist and it was documented that (R1) had bruises on (R1)’s back shoulder and waist from 06/01/2024 to 06/02/2024. It was also documented on 06/03/2024 to 06/06/2024 that (R1) has blister on (R1)’s back shoulder and waist. (S1) stated that (R1) came to the facility with bruise like rashes and denied the allegation. LPA Lee also interviewed 8 out of 8 residents who have no concern with their care from facility staff and denied any abuse from facility staff. LPA Lee interviewed (R1) who also denied the allegation of any injury and any abuse from the facility staff. LPA Lee also interviewed (R1)’s home health nurse who stated that (R1) has had the rash condition prior to coming to Vita Bella Elderly Care and that they have prescribe (R1) with anti-fungal cream. Home health nurse also stated that he/she has no concerns with the care and stated that (R1) is doing a lot better at Vita Bella Elderly Care. LPA was unable to corroborate the allegation that resident sustained unexplained injury while in care. Based on information and interview gathered there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore, the allegation is found to be unsubstantiated. An exit interview was conducted, and a copy of this report was provided to facility at the end of this visit.the state’s words, verbatim · CDSS document, Aug 12, 2024 · control 27-AS-20240611111254

Type of visit: POC

Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 08/12/2024 at 11:52 AM to conduct an unannounced Plan of Correction (POC) visit. LPA met with care giver Adi Lina Tuiloma and Aliti Waqalala and explained the purpose of the visit. The purpose of this visit is to verify the plan of correction that was required to be completed on 07/01/2024 and 07/05/2024 for deficiencies that were previously cited on a prior visit conducted on 06/24/2024. During today's visit. LPA Lee called administrator Mark Labella and left a message. Administrator was not present during today’s visit. The current census is 8 with two facility staff. Based upon this inspection, LPAs observed the following: I. The deficiency cited under Title 22 Regulation 87411(a) has not been cleared. The license did not comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. II. The deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did not comply with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. III. The deficiency cited under Title 22 Regulation 87405(d) has not been cleared. The license did not comply 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 not in compliance with Title 22 Regulation. An exit interview was conducted, and a copy of these LIC 809, LIC 809D reports and appeal rights were provided to the facility.the state’s words, verbatim · CDSS document, Aug 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Aug 16, 2024

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs… This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that a staff assisted (R1) with attending medical appointments and that (R1) was supervised. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Administrator agrees to conduct Personnel Requirements training for all facility staff who assist with residents with residents’ necessary services to meet resident’s needs. Administrator will email LPA Lee training documents used for training. Administrator will also email LPA Lee staff sign in sheet to reflect staff who received the training. POC due by 08/16/2024 by end of day 5:00 PM.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87465(a)(4) · Plan of correction due date: Aug 16, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. Based on medication audit it was learned that there were discrepancies in (R1)’s medication. Moreover, 3 out of 4 residents’ MAR logs were incomplete and are missing staff initialed; therefore, it is uncleared if residents received their medications as prescribed. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Administrator agrees to conduct Incidental medical and dental training for staff that handles residents’ medications. Administrator will email LPA Lee training materials and staff sign in sheet by POC date 08/16/2024 by end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d) · Plan of correction due date: Aug 16, 2024

87405(d) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply… This requirement is not meet as evidenced by: Based on record review and interview the licensee/administrator did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to residents in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 08/16/2024 by POC date end of day 5:00 PM.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 08/12/2024 at 10:45 AM to conduct a case management visit. LPA Lee met with care giver Adi Lina Tuiloma and Aliti Waqalala and explained the purpose of the visit. LPA Lee called administrator Mark Labella and left a message. Administrator was not present during today’s visit. The current census is 8 with two facility staff. The purpose of the visit is to follow up on deficiencies learned during complaint investigation control number # 27-AS-20240523091818. Throughout the complaint investigation, it was learned that resident 1 (R1) had an appointment on 05/17/2024 at 1:00 PM with SNAHC Medical. Based on interview with designated facility staff (S1) who admitted that (S1) did arranged transportation for (R1) to attend (R1)'s doctor appointment on 05/17/2024 and that no facility staff attended and stay with (R1) during (R1)’s doctor visit. (S1) also stated that (S1) informed the receptionist to call the facility when (R1) is done with (R1)’s appointment. (S1) admitted that (S1) didn’t supervised (R1) during (R1)’s doctor appointment because (S1) also had another appointment for herself/himself. Based on (R1)’s admission agreement on page 2 which states the facility will assist (R1) in meeting necessary medical and dental needs by arranging and assisting with incidental medical and dental services. Moreover per (R1)’s LIC 602 Physician’s Report states that (R1) is not able to leave the facility unassisted and that (R1) lacks capacity to make decisions. The following deficiencies were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. The deficiencies can be found on the 809-D page. An exit interview was conducted, and a copy of the 809 report, 809-D page, and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Aug 12, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Aug 16, 2024

§1569.312 Basic services requirements Every facility required to be licensed under this chapter shall provide at least the following basic services: (a) Care and supervision as defined in Section 1569.2. This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that a staff assisted (R1) with attending medical appointments and that (R1) was supervised. (R1) was drop off unsupervised at (R1)'s doctor's appointment. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Aug 12, 2024

Plan of correction: Licensee/administrator agrees to conduct Basic Service training for all facility staff. Licensee will submit to LPA Lee documents used for training and a sign in sheet to show staff train. Licensee will ensure that all residents are supervised at all times. POC is due by 08/16/2024 by 5:00 PM end of day.

Allegation investigated: Staff are not dispensing medications as prescribed. Staff do not assist resident with attending medical appointments. Staff are not properly supervising resident.

On 06/24/2024 at 3:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff Kirk Campbell and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 8 with 1 facility staff. During today's visit, LPA Lee called administrator Mark Labella and left a message. Administrator was not present during today's visit. A brief interview with conducted with care staff Kirk. Allegation: Staff are not dispensing medications as prescribed. It was alleged that staff are not dispensing medications as prescribed. This investigation consisted of interviews with staff and residents. LPA Lee interviewed 1 out of 6 residents who has concerned with not getting medications. LPA Lee also interview 2 out of 2 facility staff who denied the allegation. Based on residents Medication Administration Log (MAR) it was learned that 3 out of 4 resident’s MAR logs are incomplete. Continued LIC 9099-C Substantiated . Resident 2 (R2) is missing initial for the following medications for the following dates: Zyprexa Zaydis 5 MG Tablet for 05/31/2024 5:00 PM and 8:00 PM, Keppra 500 MG Tablet for 05/31/2024 5:00 PM, Gabapentin 300 MG Capsule for 05/31/2024. (R3) is missing initial for the following medications for the following dates: Quetiapine 50 MG for 05/31/2024, Oyster shell 500 MG for 05/31/2024 for 2:00 PM and 8:00 PM, Micotine Gum 2 MG for 05/31/2024 6:00 PM, Clobetasol 05/31/2024 6:00 PM, Olanzapine 10 MG for 6:00 PM, and Fenofibrate 160 MG for 05/31/2024. (R4) is missing initial for the following medications for the following dates: Norvasc 10 MG Tablet for 05/31/2024, Vitamin D3 for 05/31/2024, Nizoral 2% Shampoo for 05/31/2024, Lactulose 10 GM for 05/31/2024 8 AM, 2 PM, and 8 PM, Zyprexa 5 MG for 05/31/2024 8 AM and 5 PM, Ditropan XL 10 MG for 05/31/2024. Moreover on 05/31/2024, LPA Lee and direct care staff Theodore Patterson audit (R1)’s medication. During the medication inspection it was learned that there were discrepancies in (R1)'s medications. It was learned that (R1)'s medication for Levetiracetam 500 MG, take 2 tablets by mouth 2 times a day with start date on 03/20/2024 with 180 quantities, as of 05/31/2024 audit (R1)'s Levetiracetam medication had 13 pills remaining in the bottle which (R1) should have had 34 pills left instead. It was also learned that (R1)'s Gabapentin 300 MG take by mouth 2 times a day with a start date of 05/23/2024 is showing that (R1) did not received (R1)'s morning medication for on 05/31/2024. 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. Allegation: Staff did not assist resident with attending medical appointments and Staff are not properly supervising resident. It was alleged staff did not assist resident with attending medical appointments and staff are not properly supervising resident. This investigation consisted of record review and interviews with facility staff. LPA Lee reviewed (R1)’s admission agreement on page 2 which states (R1) the facility will assist (R1) in meeting necessary medical and dental needs by arranging and assisting with incidental medical and dental services. Moreover per (R1)’s LIC 602 Physician’s Report (R1) is not able to leave the facility unassisted and that (R1) lacks capacity to make decisions. Continued LIC 9099-C Record reviewed also revealed that (R1) had an appointment on 05/17/2024 at 1:00 PM with SNAHC Medical. Based on interview with direct care staff Theodore Patterson who admitted that she arranged transportation for (R1) to attend (R1) doctor appointment on 05/17/2024 and no facility staff attended and stay with (R1) during (R1)’s doctor visit. Direct care staff Theodore also stated that she informed the receptionist to call the facility when (R1) is done with (R1)’s appointment. 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 Kirk Campbell and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Jun 24, 2024 · control 27-AS-20240523091818

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(a) · Plan of correction due date: Jul 1, 2024

87411(a) Personnel Requirements - General Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required… This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that a staff assisted (R1) with attending medical appointments and that (R1) was supervised. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee/administrator agrees to conduct Incidental medical and dental training for all facility staff who assist with residents’ medical care and needs. Licensee/administrator will ensure that all residents are assisted with staff attending with residents during all medical appointments. Training materials along with staff sign in signatures will be email to LPA Lee by POC date of 07/05/2024 by 5:00 PM end of day.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Jul 1, 2024

87465(a)(4) Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: Based on interviews and records review: the licensee did not ensure that (R1) received (R1)’s medications as prescribed. Based on medication audit it was learned that there were discrepancies in (R1)’s medication. Moreover, 3 out of 4 residents’ MAR logs were incomplete and are missing staff initialed; therefore, it is uncleared if residents received their medications as prescribed. This posed an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: Licensee/administrator agrees to conduct Incidental medical and dental training for all Med-tech and any staff that handles residents’ medications. Licensee/administrator will email LPA Lee training materials and staff sign in sheet by POC date 07/05/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(d) · Plan of correction due date: Jul 5, 2024

87405(d) Administrator - Qualifications and Duties (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply… This requirement is not meet as evidenced by: Based on record review and interview the licensee/administrator did not comply with the section cited above. The licensee did not ensure that licensee complied with all title 22 regulations knowledge of and ability to conform to applicable laws, rules and regulations, which this poses a potential health and safety risk to residents in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jun 24, 2024

Plan of correction: The licensee will review the regulation cited and write a statement of acknowledgement of understanding of the regulation cited. POC will be emailed to LPA Lee by POC date 07/05/2024 by POC date end of day 5:00 PM.

Allegation investigated: Staff handles resident in a rough manner. Staff yells at residents in care. Staff are forcing a resident to sleep early. Staff inappropriately disciplined residents in care.

On 05/31/2024 at 2:00 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct caregiver, Theodore Patterson and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the allegations above. The current census is 7 residents with 2 facility staff presents. A brief interview with conducted with Theodore. Administrator Mark Labella was not present during today’s visit. Allegation: Staff handles residents in a rough manner. It was alleged that staff handles residents in a rough manner. This investigation consisted of observations and interviews with staff, residents, and the two outside agencies. LPA Lee interviewed 3 out of 3 facility staff who denied the allegations and has not witnessed staff handling residents in a rough manner. LPA Lee also interviewed 6 out of 6 residents who also denied the allegation that staff handled residents in a rough manner. Continued LIC 9099-C Unsubstantiated Moreover, LPA Lee interviewed a register nurse (RN) who visit the facility regularly and has not witness facility staff handled resident in a rough manner. RN stated that the days that RN is at the facility RN has only witnessed the staff being friendly to residents and puts the residents needs first even when outside agency are present and needs assistant. In addition, interview with the ombudsman, it was learned that ombudsman has no concerns with the facility through observations when the ombudsman’s been at the facility. On 04/16/2024 visit, LPA Lee observed two caregivers assisting two different residents with changing and LPA observed the two staff were gentle and provided direction of what they were doing. Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The allegation that staff handles residents in a rough manner is determined to be unsubstantiated. Allegation: Staff yells at residents in care. It was alleged that staff yells at residents in care. This investigation consisted of interviews with staff, residents, and the two outside agencies. LPA Lee interviewed 3 out of 3 facility staff who denied the allegations and stated that they have not witness any facility staff yelling at residents in care. LPA Lee also interviewed 6 out of 6 residents and 5 out of 6 residents denied the allegation that staff yells at residents in care. Moreover, LPA Lee interviewed a register nurse (RN) who visit the facility regularly and has not witness facility staff yelling at residents. RN stated that the days that RN is at the facility RN has only witnessed the staff being friendly to residents and puts the residents needs first even when outside agency are present and needs assistant. In addition, interview with the ombudsman, it was learned that ombudsman has no concerns with the facility through observations when the ombudsman’s been at the facility. Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The allegation that staff yells at resident in care is determined to be unsubstantiated. Allegation: Staff are forcing a resident to sleep early. It was alleged that staff are forcing a resident to sleep early. This investigation consisted of interviews with staff, residents, and the two outside agencies. LPA Lee interviewed 3 out of 3 facility staff who denied the allegations and stated that they have not witness any facility staff forcing a resident to sleep early. LPA Lee also interviewed 6 out of 6 residents who also denied the allegation that staff yells at residents in staff are forcing a resident to sleep early. Continued LIC 9099-C Moreover, LPA Lee interviewed a register nurse (RN) who visit the facility regularly and has not witness facility staff yelling at residents. RN stated that the days that RN is at the facility RN has only witnessed the staff being friendly to residents and puts the residents needs first even when outside agency are present and needs assistant. In addition, interview with the ombudsman, it was learned that ombudsman has no concerns with the facility through observations when the ombudsman’s been at the facility. Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The allegation that staff are forcing a resident to sleep early is determined to be unsubstantiated. Allegation: Staff inappropriately disciplined residents in care. It was alleged that staff inappropriately disciplined residents in care. This investigation consisted of interviews with staff, residents, and the two outside agencies. LPA Lee interviewed 3 out of 3 facility staff who denied the allegation and stated that they have not witness facility staff inappropriately disciplining residents in care. LPA Lee also interviewed 6 out of 6 residents who also denied the allegation that staff yells at residents in staff are forcing a resident to sleep early. Moreover, LPA Lee interviewed a register nurse (RN) who visit the facility regularly and has not witness facility staff yelling at residents. RN stated that the days that RN is at the facility RN has only witnessed the staff being friendly to residents and puts the residents needs first even when outside agency are present and needs assistant. In addition, interview with the ombudsman, it was learned that ombudsman has no concerns with the facility through observations when the ombudsman’s been at the facility. Based on the interviews and statements obtained during the investigation process, the allegation has not been corroborated. The allegation that staff inappropriately disciplined residents in care is determined to be unsubstantiated.the state’s words, verbatim · CDSS document, May 31, 2024 · control 27-AS-20240409141322

Type of visit: Collateral

Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct a collateral visit. LPA Moleski met with staff member Theodora Patterson and explained the purpose of the visit. LPA Moleski reviewed resident records and interviewed Patterson. No deficiencies were cited during this visit. An exit interview was held and a copy of this report was left with Patterson.the state’s words, verbatim · CDSS document, May 30, 2024

Type of visit: POC

Licensing Program Analysts (LPA) Pang Lee arrived at the facility on 02/15/2024 at 10:45 AM, to conduct an unannounced Plan of Correction (POC) visit. LPA met with care staff, Walesi Vakararawa and explained the purpose of the visit. The purpose of this visit is to follow-up on a plan of correction that were due on 02/09/2024. The census is 7. LPA Lee 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. On 01/09/2024, during an annual inspection, LPA Lee observed resident 1 (R1), who is non-ambulatory was residing in resident bedroom #5, which is licensed for two ambulatory residents only. On 01/30/2024, LPA Lee conducted a POC visit and POC was not cleared; therefore, LPA Lee recited the facility. On 02/07/2024, LPA Lee received an email from direct care staff Theodore Slypher informing LPA Lee that On 02/06/2024, Purls Placement Agency had moved (R2) out of the facility; therefore, (R1) has been moved to the vacant resident bedroom#3. During today’s visit, LPA Lee observed (R1) is now residing in room #3 which is licensed for two non-ambulatory residents. LPA Lee also observed resident bedroom #5 has (R3) residing in the room, who is ambulatory. On 01/09/2024 Annual Visit, it was learned that per the direction of the Metro Fire the licensee was required to put a fire door prior entering the hall way to the residents bedrooms. During today's visit, LPA Lee informed administrator, Mark Labella that he will need to update and submit to the department a new facility sketch that reflects the fire door that was placed. Based upon this inspection, the LPAs observed the following: 1. The deficiency cited under Title 22 Regulation 8720(a) has been cleared. The licensee complied with the terms of the POC by POC date of 02/09/2024. A POC letter was generated and provided to the licensee. An exit interview was conducted and a copy of this report LIC 809, LIC 811 and POC letter was given to care staff, Walesi Vakararawa.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 10:10 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by direct care staff Theodore Patterson and explained the purpose of today’s visit. The current census is 8 with 2 staff present in the facility. A brief telephone call was made to administrator Mark Labella in regard to POC. The purpose of this visit is to follow-up on two plan of corrections that was due on 01/12/2024 and 01/23/2024. LPA Lee toured and inspected the facility to ensure the deficiencies previously cited on 01/09/2024 has been corrected. It was learned that resident 1 (R1) who is non-ambulatory is still residing in bedroom #5, which is licensed for 2 ambulatory residents only. Direct care staff, Theodore informed LPA Lee that the facility cannot moved (R1) to a different bedroom since all the residents in the other bedrooms are also non-ambulatory. During today’s visit, LPA Lee recited the facility due to POC not being corrected or an POC extension was not communicated to LPA Lee. During today’s phone call with administrator Mark, he explained that he is currently working on getting resident replace through Master Care and that he is also working with Metro Fire to get bedroom #5 clear for non-ambulatory. During 01/09/2024 annual visit, LPA Lee had explained to both administrator Mark Labella via telephone and to direct care staff Theodore what the options are in regard to the citations 87202(a)(1). Again, during today’s visit LPA Lee advised administrator Mark Labella and direct care staff Theodore what those options are. LPA Lee advised that administrator need to 1. Change the fire clearance, 2. Have resident moved to a non-ambulatory bedroom and 3. Find a new placement. POC was due on 01/12/2024; however, LPA Lee did not receive any communications from the administrator in regard to POC needing to be extended. Today, LPA Lee observed and learned that the census is 8 with only 1 ambulatory resident who is already in bedroom #5 with (R1); therefore, the administrator won’t be able to move any of the other residents to bedroom #5. On 01/09/2024 and today’s visit, LPA Lee observed two facilities sketches displaced on top of a piano. Continued on LIC 809-C The first facility sketch showed resident bedroom #5 as an ambulatory room and the second facility sketch, which was behind the first facility sketch showed that resident bedroom #5 as a non-ambulatory bedroom. During today’s visit LPA Lee also advised administrator Mark that if for any reason he needs an extension on his POC it is his responsibility to notify the department. Based upon this inspection, LPA Lee observed the following: 1. Deficiency cited under Title 22 Regulation 87465(a)(4) has been cleared. The license did comply with the terms of the POC during today’s visit. During today’s visit administrator Mark asked LPA Lee to give him 10 minutes to send POC to LPA Lee email address. 2. Deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did comply with the terms of the POC and POC due date 01/12/2024 during today’s visit. As a result of this POCl visit, the facility is not in compliance with Title 22 Regulation, and the deficiency 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.the state’s words, verbatim · CDSS document, Jan 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87204(a) · Plan of correction due date: Feb 9, 2024

87204Limitations - Capacity and Ambulatory Status (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time... This requirement is not met as evidenced by: Based on observations, interviews and record review, the licensee did not comply with the section cited above. The licensee did not ensure that resident bedroom #5 is only for ambulatory resident. LPA Lee observed resident 1 (R1) residing in bedroom #5 who is non-ambulatory.the state’s words, verbatim · CDSS document, Jan 30, 2024

Plan of correction: During today’s visit, LPA Lee advised the 3 options/plan of corrections that the licensee has. Licensee will provide LPA Lee a new facility sketch, which will reflect resident room #5, LIC 200 and complete 850 to change fire clearance or continue to work with Master care in replacement or moved (R1) one to a non-ambulatory bedroom. Licensee will email LPA Lee POC by POC date 02/09/2024 by end of day 5:00 PM.

Type of visit: Required - 1 Year

On 01/09/2024 at 8:20 PM, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA Lee met with direct care staff, Theodore Patterson. A brief telephone call to administrator Mark Labella was conducted. LPA Lee explained to administrator the purpose of today’s visit. Direct care staff, Theodore Patterson assisted LPA Lee during the visit. LPA Lee explained the purpose of the visit to care staff. Administrator certificate # is 6028860740 and will expire on 07/29/2024. The current census is 8 with 2 facility staff. Administrator was not present during today’s visit. This facility is a two-story building licensed to serve 8 non-ambulatory residents, 2 ambulatory residents in bedroom #5 only and approved for 1 hospice waiver. LPA Lee 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 Lee observed resident 1 (R1) who is non-ambulatory in bedroom #5, which is fire clearance for only 2 ambulatory residents. Therefore, the facility did not adhere to the fire clearance and facility sketch. LPA Lee also observed the facility to be free of odor, clean and in good repair. LPA Lee observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA Lee toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. The hot water temperature was measured at 100.1 degrees Fahrenheit in the 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. Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in the kitchen and was last serviced on 01/04/2024. The last fire drill was conducted on 12/15/2023. LPA Lee observed the facility has a public telephone in the kitchen and the facility has the required posters posted. Continued LIC 809-C Facility thermostat observed at 79 degrees Fahrenheit. LPA Lee observed toxins located in the kitchen and laundry room are both kept locked and inaccessible to residents. LPA Lee observed sharp knives kept locked and inaccessible to residents. LPA Lee checked medication storage and found medication to be locked away and inaccessible to residents. LPA Lee reviewed and compared 4 out of 8 medication administration record (MAR) and it was not complete. LPA Lee observed (R2) Lipitor 40mg 8:00 PM medication was not marked as being given to residents from 01/01/2024 to 01/08/2024. Furthermore, it was also learned that while auditing the Lipitor 40mg medication (R2) had two extra pills left over which did not match with the start date of the medication. The first aid kit was checked and contained all the required components. LPA Lee requested residents and staff files for review. LPA Lee reviewed 5 out of 8 resident files and 3 out of 4 staff files and they were complete. LPA Lee 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 Lee (pang.lee@dss.ca.gov) by 01/16/2024 by 5:00 PM by end of day: (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610 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 immediate civil penalty was assessed during today's visit. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, LIC 421IM, LIC 811 and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Jan 9, 2024