Vita Bella Elderly Care III

Allegation investigated: Staff are forging resident documents. The Administrator is not present at the facility for a sufficient amount of time.

On 06/16/2026 at 8:35 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility staff Timoci and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 12. Allegation: Staff are forging resident documents. It was alleged that staff are forging resident documents. This investigation consisted of resident records review. On 02/13/2026 LPA Hughes conducted a visit to the facility and obtained resident LIC 602 Physician’s Reports for 14 out of 14 residents in care. LPA Hughes reviewed the records and verified that 9 out of 14 LIC 602 Physician’s Reports contained physician signatures. LPA contacted the physician’s offices and confirmed that the signatures on the LIC 602 forms were authentic and consistent with the records maintained by the physicians. There is not enough evidence to corroborate that the facility forged or falsified documents. Therefore, this allegation is unsubstantiated Continuation 9099-C Unsubstantiated Allegation: The Administrator is not present at the facility for a sufficient amount of time. It was alleged that the Facility Administrator is not present at the facility for a sufficient amount of time. This investigation consisted of interviews with the residents in care and records review. On 2/13/2026 LPA Hughes conducted a visit to the facility, during the visit LPA spoke with 8 out of 14 residents who stated that they are aware of who the facility administrator is, stating that they are always present and available at the facility. Additionally, LPA reviewed facility records LIC 500 Personnel Report which revealed the facility administrator’s presence in the facility. There is not enough information or evidence present to corroborate this allegation therefore the allegation is unsubstantiated. 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 violations occurred. Based on interviews conducted during the investigation, sufficient evidence was obtained to support the allegation that excluded individuals were permitted to be present in the facility. This was observed not in compliance with Title 22 regulation 87777(a) Exclusions as the facility did not ensure an excluded individual was not permitted to be present in the facility. 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 evidence standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility. An immediate civil penalty of $500 was assessed during today's visit.the state’s words, verbatim · CDSS document, Jun 16, 2026 · control 27-AS-20260211145020

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87777(a) · Plan of correction due date: Jun 17, 2026

87777 Exclusions (a) The Department may prohibit an individual from serving as a board of directors, executive director, or officer; being employed or allowed in a licensed facility as specified in Health and Safety Code Sections 1569.58 and 1569.59. This requirement was not met as evidenced by: The facility did not ensure excluded individuals (E1) and (E2) was prohibited from entering the facility. (E1) and (E2) was observed entering the facility on multiple occassions interacting with residents and facility staff.the state’s words, verbatim · CDSS document, Jun 16, 2026

Plan of correction: Effective immediately excluded persons will no longer be allowed to be present at a licensed facility.By POC due date, Administrator is to provide CCL with a written plan to ensure that the excluded person will not work, provide services, or interact with any of the residents or staff inside of the facility. An immediate civil penalty of $500 was assessed during today's visit.

Type of visit: Case Management - Other

On 4/29/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit was to conduct a Case Management visit the facility to discuss Technical Assistance Program (TSP) consultation services provided to the facility. LPA met with the facility administrator Sera Nakalevu. The current census is 14 with 3 facility staff present. On 3/17/2026 the facility completed consultation services with the Technical Assistance Program (TSP). LPA reviewed the TSP engagement summary with the facility administrator. The following focus areas were identified during the consultation · Recordkeeping- TSP discussed and provided training resources and recommendations including Personnel Records Guide, Resident Records Guide, Personnel/Resident File Review Checklist, Daily Resident Log, RCFE checklist · Physical Plant- TSP discussed training resources and recommendations to support continued compliance, including monitoring and oversight of the physical plant, conducting internal audits for identifying and resolving physical plant issues. · Personal Rights- TSP discussed Person-Centered care and provided the following resources and training. Personal Rights (RCFE) tool to assist the provider in understanding resident personal rights, and Personal Rights Self-Assessment Guide to assist providers as they perform periodic self-assessments of the facilities. Continuation 809-C The administrator stated that the TSP engagement was informative and provided the facility with resources and training that the facility will continue to use in the facility to ensure regulatory requirements related to the facilities physical plant and operation are consistently met. There were no deficiencies were observed or cited during today's case management visit. An exit interview was conducted and a copy of the LIC 809 reports was provided to the facility.the state’s words, verbatim · CDSS document, Apr 29, 2026

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

On 4/29/2026 Licensing Program Analyst (LPA) Shakaricka Hughes conducted an unannounced visit to the facility. The purpose of the visit was to conduct a Case Management- Quarterly visit the facility to ensure that facility remains in compliance as outlined in a NCC meeting held on 11/18/2025. LPA met with the facility administrator Sera Nakalevu, who assisted LPA during today’s visit. The current census is 14 with 3 staff present. The following items were required to be maintained in compliance while this facility is under increased monitoring with quarterly visits: Staff background checks- LPA reviewed the Guardian roster of all staff listed on the LIC 500, all staff listed were background cleared and associated with the facility. LPA advised the administrator to disassociate employees no longer working inside of the facility and accurately update work hours for employees listed on the LIC 500 report. Signal system- LPA observed a signal system in place for the facility, including attached dwelling units for resident bedrooms. The facility is in the process of changing the signal system to one single signal system for all residents’ rooms, currently the facility utilizes two separate signal systems both signal systems were observed functional and in good repair at this time. Incontinent care- LPA toured the inside of the facility including resident bedrooms and observed the facility to be clean and free of odor. Continuation 809-C Incidental Medical and Dental- LPA checked resident medications including the Medication Administration Record (MAR) and Centrally Stored Medication and Destruction Record (CSMDR) for 5 out of 14 residents in care, and it was observed complete. Food supplies- LPA observed 2-day and 7-day perishable and non-perishable food supplies for residents and both were observed sufficient to meet the needs of residents at this time. There were no deficiencies observed or cited during today's case management visit. An exit interview was conducted and a copy of this report was provided to the facility.the state’s words, verbatim · CDSS document, Apr 29, 2026

Type of visit: Required - 1 Year

On 2/4/2026 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived at the facility to conduct an unannounced annual inspection. LPA Hughes met with the facility administrator Sera Nakalevu and explained the purpose of the visit. The current census is 14 with 2 facility staff present. This facility is a single story building licensed to serve (14) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. LPA observed auditory signal systems inside the facility, and within the detached resident bedrooms outside the facility able to summon facility staff. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. LPA measured hot water temperature inside the main facility measuring 113.7 degrees F. in resident bathroom sink, LPA measured hot water temperature inside the outside resident bathroom sink measuring 111.6 degrees F. which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat in both bathrooms 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 area and was last serviced on 02/13/2025. LPA observed the facility has a public telephone in the common area and the facility has the required posters posted. Facility thermostat was observed at 74 degrees Fahrenheit. LPA observed toxins located in the laundry room kept locked and inaccessible to residents. LPA observed sharp knives kept locked in the kitchen and inaccessible to residents. Continuation 809-C LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 out of 14 residents medications and the medication administration record (MAR) was complete. The first aid kit was checked and contained the required components. LPA requested resident and staff files for review. LPA reviewed 8 out of 14 resident files and they were complete. However LPA reviewed the facility Admissions Agreements for 4 residents incomplete, as the Rate of Basic Services and Payment Provisions were incomplete. LPA reviewed 3 staff files, and it was complete. LPA reviewed staff criminal record clearances, and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared. The following documents will be email to LPA by 02/06/2026 (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 As a result of this annual visit, the facility is not in compliance with Title 22 Regulations, and the deficiency can be found on the LIC 809-D page. An exit interview was conducted with Sera 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, Feb 4, 2026

Allegation investigated: Facility is in disrepair.

On 01/21/2026 at 9:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the facility administrator Sera Nakalevu and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegation. The current census is 13. Allegation: Facility is in disrepair. It was alleged that the facility is in disrepair. This investigation consisted of interview with facility staff, residents, and facility observations. On 1/21/2026 LPA Hughes conducted a visit to the facility. LPA spoke with facility staff (S1) who stated that a concern was raised regarding an electrical outlet being in disrepair, S1 stated that the electrical outlet in resident (R1) room was repaired professionally within 3 days of being made aware of the issue. Additional interview with 4 out of 4 residents in care reported no concerns about the facility or their rooms being in disrepair. Interview with resident (R1) indicated no concerns about the facility or their room being in disrepair. Continuation 9099-C Unsubstantiated Resident (R1) stated that facility staff promptly addressed their concerns regarding an electrical outlet being in disrepair, stating that the outlet was repaired within 3 days after raising the concern to facility staff. LPA observed resident (R1) bedroom and noticed the electrical outlet to be in good repair at this time, without any cords attached to the outlet. There is not enough evidence to corroborate this allegation, therefore this allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint 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 occurred.the state’s words, verbatim · CDSS document, Jan 21, 2026 · control 27-AS-20260115155807

Allegation investigated: Staff did not prevent resident from obtaining a knife while in care.

On 12/22/2025 at 11:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with the Facility administrator Sera Nakalevu and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegation. The current census is 13. A brief interview conducted with Sera. Allegation: Staff did not prevent resident from obtaining a knife while in care. It was alleged that a staff did not prevent resident from obtaining a knife while in care. This investigation consisted of interviews with facility staff and residents. On 10/17/2025 LPA conducted a visit to the facility, during the visit LPA spoke with 3 out of 4 residents in care who all stated that the facility does not allow residents to use the kitchen unassisted. LPA spoke with 2 out of 2 facility staff who stated that residents are not allowed to use the kitchen unassisted. Continuation 9099-C Substantiated LPA attempted to obtain police reports from Sacramento Police Dept but was unable as request for reports were never returned from the Dept. There is not enough information to corroborate this allegation therefore, the allegation is unsubstantiated. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint 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 occurred Interview with facility staff (S1) stated that the knife that was obtained by resident (R1) was removed from the facility, Resident (R1) was allowed to use the kitchen unassisted, and obtained a knife from the kitchen without facility staff awareness. This was observed not in compliance with Title 22 regulation 87309 (a) Storage Space and Access. As the facility did not ensure that sharp objects were locked and inaccessible to residents in care. 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 evidence standard has been met. Deficiency cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Sera and a copy of the LIC 9099, LIC 9099-D pages and appeal rights were provided to facility.the state’s words, verbatim · CDSS document, Dec 22, 2025 · control 27-AS-20251009122801

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Dec 23, 2025

87309 Storage Space and Access(a)Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions... knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended.... This requirement was not met as evidenced by: The facility did not ensure a knife was locked and inaccessible to residents in care, which resulted in a incident involving a resident (R1) and facility staff (S2).the state’s words, verbatim · CDSS document, Dec 22, 2025

Plan of correction: Facility agrees to remain in compliance with Title 22 regulation 87309(a) at all times. Facility agrees to ensure that all knives, sharp objects, or items that could pose a danger to residents remain in a locked storage, inaccessible to residents in care. Facility agrees to assist residents in the kitchen when preparing their own meals. Facility will send a statement of acknowledgement of the Title 22 regulation 87309(a) to LPA Hughes via email by 12/23/2025.

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

Type of visit: Case Management - Other

On 10/16/2025 Licensing Program Analyst (LPA) Shakaricka Hughes and Regional Manager (RM) Stephanie Doub conducted an unannounced visit to the facility. The purpose of this visit was conduct a case management visit. LPA met with direct care staff Sera, the census is 11 residents with 3 facility staff. During a tour of the facility LPA Hughes and RM Doub observed signal systems in the bedrooms of residents in care. However when speaking with facility staff Sera it was revealed that the signal system master control receiver was missing in the facility as of 10/16/2025. Facility staff stated that the signal system master control receiver was lost and not yet found during a deep cleaning of the facility. This was observed not in compliance with Title 22 Regulation 87303(i)(1)(B) Maintenance and Operation. Facility staff stated that the signal system receiver will be replaced. Additionally, resident bedroom (1) window was observed in disrepair, as the blind was observed broken. Facility staff stated that the blind would be replaced in the resident's bedroom. This was observed not in compliance with Title 22 regulation 87303(a) Maintenance and Operation. An exit interview was conducted with Sera, and a copy of the LIC 809, and LIC 809-D was provided to the facility.the state’s words, verbatim · CDSS document, Oct 16, 2025

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(i)(1)(B) · Plan of correction due date: Oct 23, 2025

87303(i)(1)(B) Maintenance and Operation (i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. floors or buildings shall have a signal system which shall: (B) Transmit a visual and/or auditory signal to a central staff...loud enough to summon staff. This requirement is not met as evidenced by: The facility did not ensure that the signal system master receiver was available in the facility.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: The faciility will inspect the signal system and ensure that it is in good repair and that it produce an auditory signal to where its alert staff. A statement of acknowledgment of reviewing the regulation cited will be email to LPA Hughes by 10/23/2025.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Oct 23, 2025

87303 Maintenance and Operation (a) 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. 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: The facility did not ensure that a resident's bedroom window blind was in good repair. Facility stated that the window blind will be replaced.the state’s words, verbatim · CDSS document, Oct 16, 2025

Plan of correction: The facility will ensure that the facility is in good repair at all time. The facility will replace the window blind in the resident's bedroom. A statement of acknowledgment of reviewing the regulation cited, and proof of window blind replacement will be emailed to LPA Hughes by 10/23/2025.

Type of visit: Case Management - Other

On 08/28/2025 at 4:32 PM Licensing Program Analyst LPA's Shakaricka Hughes and Pang Lee arrived at the facility to conduct a case management visit to deliver an Order to Licensee/Facility of Immediate Exclusion from Facility. LPA met with facility staff Adilina Tuiloma and explained the purpose of today's visit. LPA Hughes handed the Order to Licensee/Facility of Immediate Exclusion from Facility letter to care staff Adilina Tuiloma 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 care staff Adilina Tuiloma and a copy of this report was provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Allegation investigated: Staff hit a resident while in care Staff did not prevent resident from harming another resident in care

On 08/11/2025 at 11:00 AM, Licensing Program Analyst (LPA) Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPA met with Facility staff Nina Tuiloma and explained the purpose of the visit. The purpose of this visit is to deliver complaint findings for the above allegations. The current census is 13. A brief interview conducted with Nina. Allegation: Staff hit a resident while in care It was alleged that facility staff hit a resident while in care. This investigation consisted of interviews with residents and facility staff. On 6/3/2025 LPA Gould conducted a visit to the facility. LPA interviewed 3 out of 5 residents in care, who all stated they have no concerns with staff hitting residents in care. Interviews with 2 out of 3 facility staff reflected that staff have not hit nor witnessed other care staff hit residents in care. An interview with facility staff (S3) reflected that they have never hit a resident in care. An interview conducted with Resident (R1) revealed that the resident could not recall the information needed to corroborate the allegation. Therefore, there was not enough information to corroborate the allegation. Continuation 9099-C Unsubstantiated Allegation: Staff did not prevent resident from harming another resident in care It was alleged that facility staff did not prevent a resident from harming another resident in care. This investigation consisted of interviews with staff and residents, and records review. On 6/3/2025 LPA Gould conducted a visit to the facility. LPA interviewed 3 out of 5 residents, all residents interviewed reported having no concern regarding conflicts between residents. On 8/3/2025 LPA Hughes conducted a follow-up visit to the facility interview with 3 out 3 facility staff revealed that staff had no concerns about residents in care harming other residents. During an interview with Resident (R1) they were unable to recall details relevant to corroborating the information. A review of records, Special Incident Reports (SIR) from 5/22- 5/29/2025 sent to CCLD, indicated that staff intervened promptly between conflicts involving R1 and other residents in care, and redirected residents involved preventing further escalation of conflict. There was not enough evidence to support the allegation, therefore the above allegation could not be corroborated at this time. 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 violations occurred.the state’s words, verbatim · CDSS document, Aug 14, 2025 · control 27-AS-20250530153105

Allegation investigated: Facility did not seek medical attention in a timely manner.

On 04/23/25, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care giver Lina Tuilona and explained the purpose of the visit. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 12. A brief interview with conducted with administrator Cleopatra Gardiner via telephone call. It was alleged that the facility did not seek medical attention for a resident in a timely manner. The investigation included interviews with facility staff and residents, as well as a review of relevant records. LPA Lee interviewed three staff members, all of whom denied the allegation. The facility staffs stated that Resident 1 (R1) was transported to the emergency room the day after an unwitnessed fall. LPA Lee also interviewed four out of four residents, all of whom expressed no concerns regarding facility staff not seeking medical attention to residents in care Continued LIC 9099-C Unsubstantiated . Resident 2 (R2), who shares a room with R1, reported witnessing R1 fall from R1’s wheelchair on 02/09/25. R2 stated that R2 immediately sought assistance from facility staff 1 (S1), who responded and attended to R1. Despite the fall being unwitnessed by staff, the facility contacted emergency medical services on 02/10/25, and R1 was transported to Kaiser South for evaluation. According to R1’s After Visit Summary from Kaiser, R1 was admitted on 02/10/25 for a fall with a discharge date of 02/12/25. Medical documentation noted: “No acute hemorrhage. No mass effect or herniation. No acute intracranial injury.” The facility’s Plan of Operation outlines that emergency medical services (911) will be summoned immediately if a resident shows sign of distress (e.g., shortness of breath, chest pain, changes in consciousness). For non-serious emergencies, as determined by the administrator or supervisor on duty, the resident will be treated with first aid. In this case, the facility followed protocol and R1 assessed R1 during the fall and R1 was provided medical attention the next day. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation is found to be UNSUBSTANTIATED. A finding that the complaint allegation us UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation(s)occurred.the state’s words, verbatim · CDSS document, Apr 23, 2025 · control 27-AS-20250211104147

Allegation investigated: Staff restrained resident to wheelchair.

On 03/24/25, Licensing Program Analysts (LPAs) Pang Lee and Shakaricka Hughes arrived unannounced to this facility to conduct a complaint visit. LPAs met with direct care staff Adi Lina Tuiloma and explained the purpose of the visit. Care Staff Adi Lina Tuiloma informed administrator Cleopatra Gardiner that Community Care Licensing Department (CCLD) was present in the facility. The purpose of this visit is to deliver complaint finding for the allegation above. The current census is 13 with 3 facility staff. A brief interview with administrator Cleopatra Gardiner was conducted over the telephone to go over the complaint finding. It was alleged that staff restrained resident to a wheelchair. The investigation involved conducting interviews and reviewing records. In interviews with 2 out of 2 facility staff they admitted that Resident 1 (R1) was restrained to a wheelchair. Continued LIC 9099-C Substantiated During an interview with Staff 1 (S1), S1 explained that R1 had a belt attached to the wheelchair, and S1 would strap R1 into the belt for security reasons. S1 clarified that the belt was not used all the time but would be applied when S1 was not nearby R1. S1 stated S1 used the belt about once or twice. In a separate interview, S2 confirmed that S2 believed the belt was being used and saw something on R1’s waist. However, upon reviewing the R1’s records, it was learned that R1 did not have a written physician's order for the use of the belt nor consent from R1's responsible party. As a result, this allegation is SUBSTANTIATED. A finding that the complaint is substantiated means that the allegations are valid because the preponderance of the standard has been met. Deficiencies cited on the LIC 9099-D, per Title 22 Regulations. An exit interview was conducted with Tasha and Melissa and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Mar 24, 2025 · control 27-AS-20250225081441

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87608(a)(3) · Plan of correction due date: Mar 31, 2025

87608(a)(3) Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident… (3) A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record... This requirement was not met as evidence by: The facility used a belt on R1 without a written physician’s order in place.the state’s words, verbatim · CDSS document, Mar 24, 2025

Plan of correction: Administrator agrees to ensure that a written physician’s order is in place prior to using any postural support. Administrator agrees to review the regulation cited and provide postural support training to all staff and provide LPA Lee training documents used for the training with staff sign in sheets and statement of acknowledgement of reading and understanding the regulation cite by POC date 03/31/25 end of day 5:00 PM.

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 03/04/25 at 10:12 AM to conduct an unannounced Plan of Correction (POC) visit. LPA met with care staff Adi Lina Tuiloma and explained the purpose of the visit. The purpose of this visit was to verify the plan of correction that was required to be completed on 02/28/25 for deficiencies that were previously cited on a prior visit conducted on 02/20/25. The current census is 14 with 3 facility staff. During today's visit, LPA conducted a tour of the facility and tested the signal system with direct care staff Adi Lina. Based on observation a new signal system was purchased and installed and observed to be in good repair. The signal system also emits an auditory signal to the staff central location of the facility. LPA Lee also observed toxins and sharp knifes kept locked and inaccessible to residents in care. Based upon this inspection, LPA observed the following: 1. The deficiency cited under Title 22 Regulation 87309(a) has been cleared. The license did complied with the terms of the POC-by-POC due date. A POC letter was generated and provided to the licensee. 2. The deficiency cited under Title 22 Regulation 87303(i)(1)(B) has been cleared. The license complied with the terms of the POC-by-POC due date. A POC letter was not generated and provided to the licensee. As a result of this, POC visit the facility is in compliance with Title 22 Regulation. No other deficiencies were observed or cited during today’s Plan of Correction visit. An exit interview was conducted, and a copy of these LIC 809 reports were provided to the facility.the state’s words, verbatim · CDSS document, Mar 4, 2025

Type of visit: Required - 1 Year

On 02/20/25, Licensing Program Analyst (LPA) Pang Lee arrived at the facility to conduct an unannounced annual inspection. LPA met with administrator Cleopatra Gardiner and explained the purpose of the visit. The current census is 13 with 3 facility staff. This facility is a single story building licensed to serve fourteen (14) non-ambulatory residents. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry room and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility to be free of odor, clean and in good repair. LPA observed bedrooms to be properly furnished with appropriate bedding and lighting. There are no bodies of water present. LPA toured the kitchen and observed sufficient seven-day non-perishable and two-day perishable food supplies. At 1:16 PM, LPA observed a knife made accessible to residents in care. LPA observed the administrator and another staff member preparing lunch for the residents. After lunch was served, the knife was placed in the kitchen sink, and staff walked away. LPA addressed this issue with the administrator, who then locked the knife in a kitchen cabinet. Additionally, LPA observed toxic substances were stored under the kitchen sink, and it was unlock making it accessible to residents. LPA advised the administrator to secure the cabinet. LPA and the administrator also tested two residents’ call pendants, which appeared to function properly but did not emit an auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff. Hot water temperature was measured at 111.2 degrees Fahrenheit in resident bathroom sink, which is within the required regulation of 105 to 120 degrees Fahrenheit. Grab bars and non-slip mat were observed to be stable and in good repair at this time. Continued LIC 809- Smoke and carbon monoxide detectors are in compliance with fire safety. The fire extinguisher is located in kitchen and was last serviced on 02/13/25. LPA observed the facility has a has a public telephone in the kitchen. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA reviewed 6 out of 13 residents’ medications and medication administration record (MAR) and it was complete. The first aid kit was checked and contained the required components. LPA requested residents and staff files for review. LPA reviewed 7 out of 13 resident files and it was incomplete. Based on records review LPA observed the following in residents’ file: · R3 did not have LIC 601 · R4 LIC 601 was incomplete. · R6 LIC 601 is incomplete, LIC 627C is blank and needs resident and administrator’s signature. · R7 LIC 625 is missing administrator’s signature. LPA Lee also reviewed 3 staff files, and they were also incomplete. Based on records review LPA observed the following in staff files: · Staff 1(S1) LIC 501 is missing staff’s previous employment and education. LPA also did not see first aid/CPR in the staff file. · S2 LIC 501 is missing employment and education. · S3 does not have 20 hours of continual education for 2024. During today’s visit, the administrator addressed and corrected the incomplete documents for both residents and staff. Administrator was able to locate S1’s first aid/CPR certificate. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. The following documents will be email to LPA during by 02/26/25 end of day 5:00 PM. (1) LIC 308 Designation of Administrative Responsibility (2) LIC 500 Personnel Report (3) Copy of Administrator Certificate (4) LIC 610D Emergency Disaster Plan (5) Proof of Current Liability Insurance As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Feb 20, 2025

The state marks this report as 7 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

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 7 Type A citations and 13 Type B citations since 05/19/2023. 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) Continued LIC 809-C · 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 ensure gates in the facility are self-latch/close 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 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: Case Management - Deficiencies

Licensing Program Analysts (LPAs) Pang Lee and Arielle Pascua arrived at this facility unannounced on 11/27/2024 to conduct a case management visit. LPAs met with direct care staff Jemesa Aisake and explained the purpose of the visit. The purpose of this visit is to amend visit report dated on 11/21/2024 to generate LIC 809-D and civil penalty. The census is 9. Based on records review it was learned that resident 1 (R1) was admitted to the facility on 11/09/2023. According to R1’s LIC 625 Appraisal/Needs and Service Plan, there was no indication that R1 required assistance with feeding. However, based on an LIC 624 incident report dated 05/22/2024, R1 was admitted to Methodist Hospital of Sacramento after care staff observed R1 coughing profusely during a meal. The coughing persisted even as staff assisted with feeding. The Methodist Hospital Emergency Documentation recommended that R1 be placed on a soft, bite-sized diet with thin liquids. However, the facility did not update R1’s LIC 625 Appraisal/Needs and Service Plan to reflect this recommendation. The interviews with care staff, revealed staff were aware of R1’s dietary needs, including the need for food to be cut into small pieces, as well as R1’s tendency to eat too quickly. Despite this, the facility did not update R1’s LIC 625 Needs and Service Plan and Reappraisals to reflect these changes. The facility administrator did not report the changes to R1’s physicians so that the physician’s report could also be updated. Additionally, R1 was accepted into and retained at the home, where R1 require assistance with all activities of daily living, as outlined in R1's LIC 625 Needs and Service Plan and confirmed during an interview with Administrator Cleopatra Gardiner and direct care staff Jemesa Aisake. Furthermore, there were no exceptions made for R1, as R1 is not receiving hospice care. On 11/21/2024, LPA Lee observed a volunteer staff (VS) present in the facility. It was observed that VS was assisting with sweeping, changing residents’ sheets, socializing with the residents, and shadowing the caregivers. Based on records review VS is does not have a California clearance and is not associated to the facility. On 11/21/2021, LPA Lee also delivered an Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately. The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report, exclusion letter and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Nov 27, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(g)(2) · Plan of correction due date: Dec 4, 2024

87411(g)(2)Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance... This requirement was not met as evidence by: This requirement was not met as evidence by: Based on interviews, observations and record review, on 11/21/24 the facility did not ensure the volunteer staff has a California clearance and associated to the facility. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Nov 27, 2024

Plan of correction: Administrator agrees to conduct a Personnel Requirements in service training with facility staff. Training materials and sign in sheets will be provided to LPA. Administrator will also review the regulation cited and provide LPA a statement of acknowledgement and understating of the regulation cite. POC due to LPA by 12/04/24 end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(a)(3) · Plan of correction due date: Dec 4, 2024

87463(a)(3) Reappraisals: the pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes...reappraisals shall document changes in the resident's physical, medical, mental, and social condition...Any illness, injury, trauma, or change in the health care needs This requirement was not met as evidence by: Based on interviews and record review, the facility did not conduct a reappraisal after R1 returned from the hospital. This posed an immediate health and safety risk to R1.the state’s words, verbatim · CDSS document, Nov 27, 2024

Plan of correction: Administrator agrees to conduct a reappraisal in service training with facility staff. Training materials and sign in sheet will be provided to LPA. Administrator will also review the regulation cited and provide LPA a statement of acknowledgement and understating of the regulation cite. POC due to LPA by 12/04/24 end of day 5:00 PM.

Allegation investigated: Due to staff neglect, resident choked while eating resulting in death

On 11/19/2024, Licensing Program Analyst (LPA) Pang Lee arrived at the facility unannounced to deliver complaint finding. LPA met with care giver Jemesa Aisake. LPA asked for caregiver Jemesa to call administrator Cleopatra Gardiner to informed that CCLD is present. During today's visit administrator was not present. The census is 9. It was alleged that due to staff neglect, resident choked while eating resulting in death. Throughout the course of this investigation, the Department conducted interviews and reviewed facility records. The investigation revealed that on 06/11/2024, resident (R1) choked on food while in care at Vita Bella Elderly Care III. While (R1) was conscious and alert, staff 1 (S1) conducted the Heimlich maneuver, while S2 called 911 and followed instructions to administer cardiopulmonary resuscitation (CPR). The investigation revealed multiple staff are aware of R1’s inability to eat food independently. The staff prepare R1’s food by cutting the food in small pieces and serving soft items and per staff interviews, staff sit and feed R1 with each meal. Sacramento Fire Department paramedics arrived and pronounced R1 deceased at the scene. Due to the above noted information, there is not a preponderance of evidence to prove the alleged violation did or did not occur, and therefore the allegation is unsubstantiated. An exit interview was conducted, and a copy of this report was provided to the facility. Unsubstantiatedthe state’s words, verbatim · CDSS document, Nov 21, 2024 · control 27-AS-20240722155157

Type of visit: Case Management - Deficiencies

THIS REPORT WAS AMENDED AND A NEW 809 DATED ON 11/27/2024 NOW SUPERSEDES IT. Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 11/21/2024 to conduct a case management visit. LPA Lee met with direct care staff Jemesa Aisake and explained the purpose of the visit. LPA Lee requested for care staff to call administrator Mark Labella to inform that CCLD is present in the home. It was confirmed with administrator Mark Labella that he is not able to be present during today’s visit. LPA Lee spoke with administrator Mark regarding the purpose of today’s visit. The purpose of this visit is to follow-up on deficiencies learned during complaint investigation control number # 27-AS-20240722155157. The census is 9. Based on records review it was learned that resident 1 (R1) was admitted to the facility on 11/09/2023. According to R1’s LIC 625 Appraisal/Needs and Service Plan, there was no indication that R1 required assistance with feeding. However, based on an LIC 624 incident report dated 05/22/2024, R1 was admitted to Methodist Hospital of Sacramento after care staff observed R1 coughing profusely during a meal. The coughing persisted even as staff assisted with feeding. The Methodist Hospital Emergency Documentation recommended that R1 be placed on a soft, bite-sized diet with thin liquids. However, the facility did not update R1’s LIC 625 Appraisal/Needs and Service Plan to reflect this recommendation. The interviews with care staff, revealed staff were aware of R1’s dietary needs, including the need for food to be cut into small pieces, as well as R1’s tendency to eat too quickly. Despite this, the facility did not update R1’s LIC 625 Needs and Service Plan and Reappraisals to reflect these changes. The facility administrator did not report the changes to R1’s physicians so that the physician’s report could also be updated. Additionally, R1 was accepted into and retained at the home, where R1 require assistance with all activities of daily living, as outlined in R1's LIC 625 Needs and Service Plan and confirmed during an interview with Administrator Cleopatra Gardiner and direct caregiver Jemesa Aisake. Furthermore, there were no exceptions made for R1, as R1 is not receiving hospice care. Continued LIC 809-C LPA Lee observed a volunteer staff (VS) present in the facility. It was observed that VS was assisting with sweeping, changing residents’ sheets, socializing with the residents, and shadowing the caregivers. Based on records review VS is does not have a California clearance and is not associated to the facility. During today’s visit, LPA Lee also delivered an Order to Licensee/Facility of Immediate Exclusion and explained that staff (S1) is excluded from any involvement in the facility effective immediately. The following deficiency were observed and cited from the California Code of Regulations, Title 22, and California Health and Safety Code. An exit interview was conducted, and a copy of this LIC 809 report, exclusion letter and appeal rights were given to the facility.the state’s words, verbatim · CDSS document, Nov 21, 2024

Allegation investigated: Incident Reports are not reported as required. Administrator does not spend sufficient number of hours at the facility.

On 09/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Aisake Jemesa and Alita Natoga and explained the purpose of the visit. LPA called licensee Mark Lablla and left a message. LPA also called administrator Cleopatra Gardiner and explained the purpose of this visit is to deliver complaint findings for the allegations above. The current census is 10 with 2 facility staff. Approximately 20 minutes later administrator arrived at the facility. Licensee Mark Labella who was the previous administrator was not present at the facility. Allegation: Incident Reports are not reported as required. It was alleged that incident reports are not reported as required. This investigation consisted of interview with facility staff and records reviewed. LPA Lee interviewed 4 facility staff who stated that incident reports are reported to the administrator Mark Labella and that the administrator then will report incident reports to the department. During 07/22/24 facility visit, LPA Lee observed a binder with multiple handwritten LIC 624 incident reports. Continued LIC 9099-C Substantiated LPA Lee requested copies of the incident reports from the binder. LPA Lee was provided with 23 LIC 624 Incident Report for the year of 2023 and 9 LIC 624 Incident Report for the year of 2024. LPA Lee reviewed incident report and multiple incident report does not indicate that the incident report was reported to the department. Based on incident report that was provided to LPA there were 3 Absent Without Leave (AWOL), 3 deaths, 1 resident found unresponsive, 2 wound care concerns where resident was sent out to the hospital and an incident where a staff found a resident with a knife in resident’s hand trying to slit resident’s wrist. LPA Lee also reviewed the department’s Electronic Facility Files where facilities incident report that are faxed to the department are saved and there was no incident report in the Electronic Facility Files from Vita Bella Elderly Care III. Furthermore, the facility was not able to provide proof of the multiple incident reports as ever faxed or reported to the department. Moreover, on 09/03/2024, LPA Lee reached out to Licensee Mark Labella regarding an incident where a resident choked and then was pronounced decease, to see if the incident was reported to the department. On 09/09/2024, administrator emailed LPA Lee a screen shot of a document faxed to the department; however, LPA Lee was not able to confirm what was faxed to the department since it was only a screen shot. On 09/09/24, LPA Lee requested to have the fax forwarded to LPA Lee since the facility uses Fax.com Email to fax documents, the administrator was not able to forward the fax to LPA Lee and provide proof that multiple incident reports were reported to the department. Allegation: Administrator does not spend sufficient number of hours at the facility. It was alleged that Administrator does not spend sufficient number of hours at the facility. This investigation consisted of interview with facility staff and residents, observations and records reviewed. LPA Lee interviewed 4 facility staff who confirmed that administrator Mark Labella comes to the facility once a week to tour the facility and provided the facility with materials that are needed. The facility staff confirmed that the administrator is at the facility 4 times a month. LPA Lee also spoke to two individuals who used to work at Vita Bella Elderly Care III, who stated that administrator is not at the facility and only see the administrator 3-4 times a month. LPA Lee also interviewed 6 residents who stated that they don’t know the name and who the administrator is and thought that designated/caregiver staff Cleopatra Gardiner was the administrator. Moreover, based on records review, LIC 500 the administrators’ scheduled is Tuesday from 2:00 PM to 6:00 PM, Thursday from 12:00 PM to 5:00 PM, Friday from 2:00 PM to 6:00 PM. Based on previous facility visit and observation, LPA Lee did not observe the administrator Mark Labella present in the facility during the following facility visits:06/06/23, 09/12/23, 09/26/23, 10/05/23, 10/20/23, 10/24/23, 10/25/23, 11/13/23, 11/21/23, 01/10/24, 01/30/24, 03/05/24, 04/11/24, 05/16/24, and 07/24/24. As of 07/24/2024, LPA Lee still have not receive any LIC 624 Incident Reports from the facility. 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 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 27-AS-20240722155157

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 27, 2024

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by Based on the file reviews and interviews, the Licensee did not ensure facility reported multiple incidents reports to CCLD. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Administrator agrees to conduct a reporting in-service training by 09/27/24. Training materials and staff sign in sheet will also be email to LPA Lee. Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 27, 2024

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility… This requirement is not met as evidenced by Based on observation and facility visits, the Administrator has not been at facility for a sufficient number of hours and adhere to the facility LIC 500 Personnel Report.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Licensee/Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.

Allegation investigated: Incident Reports are not reported as required. Administrator does not spend sufficient number of hours at the facility.

On 09/18/2024 at 8:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with care staff Aisake Jemesa and Alita Natoga and explained the purpose of the visit. LPA called licensee Mark Lablla and left a message. LPA also called administrator Cleopatra Gardiner and explained the purpose of this visit is to deliver complaint findings for the allegations above. The current census is 10 with 2 facility staff. Approximately 20 minutes later administrator arrived at the facility. Licensee Mark Labella who was the previous administrator was not present at the facility. Allegation: Incident Reports are not reported as required. It was alleged that incident reports are not reported as required. This investigation consisted of interview with facility staff and records reviewed. LPA Lee interviewed 4 facility staff who stated that incident reports are reported to the administrator Mark Labella and that the administrator then will report incident reports to the department. During 07/22/24 facility visit, LPA Lee observed a binder with multiple handwritten LIC 624 incident reports. Continued LIC 9099-C Substantiated LPA Lee requested copies of the incident reports from the binder. LPA Lee was provided with 23 LIC 624 Incident Report for the year of 2023 and 9 LIC 624 Incident Report for the year of 2024. LPA Lee reviewed incident report and multiple incident report does not indicate that the incident report was reported to the department. Based on incident report that was provided to LPA there were 3 Absent Without Leave (AWOL), 3 deaths, 1 resident found unresponsive, 2 wound care concerns where resident was sent out to the hospital and an incident where a staff found a resident with a knife in resident’s hand trying to slit resident’s wrist. LPA Lee also reviewed the department’s Electronic Facility Files where facilities incident report that are faxed to the department are saved and there was no incident report in the Electronic Facility Files from Vita Bella Elderly Care III. Furthermore, the facility was not able to provide proof of the multiple incident reports as ever faxed or reported to the department. Moreover, on 09/03/2024, LPA Lee reached out to Licensee Mark Labella regarding an incident where a resident choked and then was pronounced decease, to see if the incident was reported to the department. On 09/09/2024, administrator emailed LPA Lee a screen shot of a document faxed to the department; however, LPA Lee was not able to confirm what was faxed to the department since it was only a screen shot. On 09/09/24, LPA Lee requested to have the fax forwarded to LPA Lee since the facility uses Fax.com Email to fax documents, the administrator was not able to forward the fax to LPA Lee and provide proof that multiple incident reports were reported to the department. Allegation: Administrator does not spend sufficient number of hours at the facility. It was alleged that Administrator does not spend sufficient number of hours at the facility. This investigation consisted of interview with facility staff and residents, observations and records reviewed. LPA Lee interviewed 4 facility staff who confirmed that administrator Mark Labella comes to the facility once a week to tour the facility and provided the facility with materials that are needed. The facility staff confirmed that the administrator is at the facility 4 times a month. LPA Lee also spoke to two individuals who used to work at Vita Bella Elderly Care III, who stated that administrator is not at the facility and only see the administrator 3-4 times a month. LPA Lee also interviewed 6 residents who stated that they don’t know the name and who the administrator is and thought that designated/caregiver staff Cleopatra Gardiner was the administrator. Moreover, based on records review, LIC 500 the administrators’ scheduled is Tuesday from 2:00 PM to 6:00 PM, Thursday from 12:00 PM to 5:00 PM, Friday from 2:00 PM to 6:00 PM. Based on previous facility visit and observation, LPA Lee did not observe the administrator Mark Labella present in the facility during the following facility visits:06/06/23, 09/12/23, 09/26/23, 10/05/23, 10/20/23, 10/24/23, 10/25/23, 11/13/23, 11/21/23, 01/10/24, 01/30/24, 03/05/24, 04/11/24, 05/16/24, and 07/24/24. As of 07/24/2024, LPA Lee still have not receive any LIC 624 Incident Reports from the facility. 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 and a copy of this LIC 9099, LIC 9099-D page and appeal rights provided to facility.the state’s words, verbatim · CDSS document, Sep 18, 2024 · control 27-AS-20240722155157

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1)(D) · Plan of correction due date: Sep 27, 2024

87211(a)(1)(D) Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence… (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. This requirement is not met as evidenced by Based on the file reviews and interviews, the Licensee did not ensure facility reported multiple incidents reports to CCLD. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Administrator agrees to conduct a reporting in-service training by 09/27/24. Training materials and staff sign in sheet will also be email to LPA Lee. Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 27, 2024

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility… This requirement is not met as evidenced by Based on observation and facility visits, the Administrator has not been at facility for a sufficient number of hours and adhere to the facility LIC 500 Personnel Report.the state’s words, verbatim · CDSS document, Sep 18, 2024

Plan of correction: Licensee/Administrator shall submit a statement of understanding regarding the reporting requirements outlined in 87211 regulations by POC date 09/27/24 end of day via email.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Sep 27, 2024

THIS REPORT IS AMENDED TO REMOVED THE DOUBLE CITATION FOR 87405(a).the state’s words, verbatim · CDSS document, Sep 18, 2024

Allegation investigated: Resident sexually assaulted another resident in care.

On 05/16/2024 at 12:49 PM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff Cleopatra Gardiner and Rorrie Hylton and explained the purpose of the visit. The purpose of this visit is to follow-up and deliver complaint finding for the allegation above. The current census is 11 with 3 care staff. The administrator Mark Labella was not present during today’s visit. Allegation: Resident sexually assaulted another resident in care. It was alleged that resident sexually assaulted another resident in care. This investigation consisted of interviews with facility staff and residents. LPA Lee interview 3 facility staff who denies the allegation and has not witnessed another resident being sexually assaulted by another resident. LPA Lee also interviewed 3 out of 3 residents who denies the allegations and stated that they have not heard, or witness resident being sexually assaulted by another resident in care. Continued LIC 9099-C Unsubstantiated LPA Lee attempted to get a hold of resident 1 (R1); however, the contact number for (R1) is no longer associated to (R1). LPA Lee also attempted to contact (R1)’s emergency contact number and it was learned that those contact numbers are no longer in services. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, the department was unable to corroborate the allegations. 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 resident sexually assaulted another resident in care is 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. An exit interview was conducted with facility direct care staff Cleopatra Gardiner and a copy of this report was given to Cleopatra.the state’s words, verbatim · CDSS document, May 16, 2024 · control 27-AS-20230925082209

Allegation investigated: Staff mismanages resident's medications. Medications are made accessible to residents. Staff are not meeting resident's incontinence needs. Staff did not treat resident with dignity and respect.

On 04/10/2024, Licensing Program Analyst (LPA) Pang Lee and Licensing Program Manager Czarrina Camilon-Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee and LPM Camilon-Lee met with administrator Mark Labella and direct care staff, Cleopatra Gardiner 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 12 with 2 facility staff. A brief interview was conducted with administrator Mark Labella Allegation: Staff mismanages resident's medications. It was alleged that facility staff mismanaged resident's medications. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 5 out of 5 residents who denies the allegation that facility staff mismanages residents’ medication. Two facility staff also denied the allegation. Moreover, resident 1 (R1) denies the allegation and stated that (R1) knows what medication (R1) is given and has no concerns with the facility staff mismanaging (R1)’s Medications. Continued LIC 9099-C Unsubstantiated LPA Lee also reviewed (R1)’s MAR log sheet and compared the MAR log sheet to (R1)’s medication and it was learned that resident’s medication matches and medications on the log sheet. Furthermore, LPA Lee conducted 3 medication audit and there were no discrepancies. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means 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. Allegation: Staff are not meeting resident's incontinence needs. It was alleged that facility staff are not meeting resident's incontinence needs. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 5 out of 5 residents who denies the allegation that facility staff are not meeting resident's incontinence needs. Two facility staff also denied the allegation. On 03/13/2024, LPA Lee observed staff 1 (S1) providing incontinence care to two residents. LPA Lee reviewed 5 out of 5 Client Care Daily Checklist and records reviewed indicates that 5 out of 5 clients incontinence needs are provided. Moreover, (R1) denies the allegation that facility staff are not meeting (R1)’s incontinence needs. (R1) stated that (R1) is independent and does all (R1)’s ADL needs and that facility staff does help (R1) when needed. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation was found to be UNSUBSTANTIATED finding that the complaint allegations are UNSUBSTANTIATED means is 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. Allegation: Staff did not treat resident with dignity and respect. It was alleged that facility Staff did not treat resident with dignity and respect. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 5 out of 5 residents who denies the allegation that facility staff are not treating resident with dignity and respect. Two facility staff also denied the allegation. Moreover, resident 1 (R1) denies the allegation and stated that he/she has no concerns and does feel safe living at the home. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation was found to be UNSUBSTANTIATED. A finding that the complaint allegations are UNSUBSTANTIATED means is 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. Allegation: Medications are made accessible to residents. It was alleged that medications are made accessible to residents. This investigation consisted of records reviewed, interviews with staff and residents. LPA Lee interviewed 5 out of 5 residents and 2 out of those 5 residents admitted to the allegations. Two facility staff also admitted to the allegations. Throughout the investigation it was learned that (R1) was admitted to the facility on 02/09/2024 and residents’ medication came from the hospital with (R1). It was also learned that (S2) conducted an intake of (R1)’s medications that came with (R1) on 02/09/2024 and (S2) locked up those medications. Based on interviews, (R1) made arrangement with the bunker where (R1) lived prior to being admitted to the hospital and then from the hospital to this facility to have (R1)'s personal belongings delivered to the facility. (R1) admitted that when (R1)’s personal belonging arrived at the facility (R1) did not informed facility staff that (R1) has medications in (R1)’s personal belongings that was delivered. (R1) admitted that (R1) thought it was okay for (R1) to keep (R1)’s medication in (R1)’s room since it was okay for (R1) to keep (R1)’s medication in (R1)’s room when (R1) was living at the bunker. (R1) also admitted that (S2) did asked (R1) what was in (R1)’s garbage bags that was delivered and (R1) responded that they were only clothes and food in the garbage bags. Moreover, (S2) admitted that (S2) found (R1)’s medication in (R1)’s room the next morning when (S2) helped (R1) clean and un-bag (R1)’s personal belongings. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation was found to be UNSUBSTANTIATED finding that the complaint allegations are UNSUBSTANTIATED means is 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. LPA Lee did issue a Technical Assistant to ensure that when residents belongings are delivered to the facility that facility staff will conduct an audit check list to ensure residents medications are not made assessable to residents in care. Per California Code of Regulations (CCRs) - Title 22, Division 6, Chapter 6, no deficiency is cited. A copy of this report was provided, and LIC 811, the Confidential Names List. Exit interview.the state’s words, verbatim · CDSS document, Apr 11, 2024 · control 27-AS-20240308101336

Type of visit: Case Management - Health Checks

On 03/05/2024 at 1:00 PM, Licensing Program Analyst (LPA) Pang Lee and Ombudsman Ron Carrera arrived at the facility unannounced to conduct a health and safety case management visit. LPA Lee met with direct care staff Cleopatra Gardiner and explained the purpose of the visit. The census is 12 with 2 facility staff presents. Upon arrival to the facility LPA Lee and Ombudsman Carrera observed a resident walking back to the facility. It was learned that the resident walked to the park to feed the squirrels. LPA Lee and Ombudsman Carrera took a tour of the facility at approximately 1:25 PM, LPA Lee observed 5 resident in the common area sitting on the sofa watching TV, three residents was observed in their room laying down on their bed, it was informed that one resident was in the shower, another resident was observed sitting outside on the patio and another resident was out in the community and arrived back to the facility at 3:00 PM. LPA observed medications, sharp objects and toxins made inaccessible to residents in care. LPA observed the residents beds were clean and sanitary. Common area for resident use was observed to have appropriate furniture and in good repair at this time. LPA Lee toured the kitchen and observed sufficient seven day non-perishable and two day perishable food supplies. LPA Lee conducted 8 residents interview and 8 out of 8 residents have no concerns with the facility and facility staff. No deficiencies cited during this visit. An exit interview was conducted with direct care staff Cleopatra Gardiner and a copy of this report was given to the facility.the state’s words, verbatim · CDSS document, Mar 5, 2024

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 01/30/2024 at 8:24 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by direct care staff Cleopatra Garnier and explained the purpose of today visit. The current Census is 12 with 2 staff present in the facility. A brief telephone call was made to administrator Mark Labella in regard to POC training materials. The purpose of this visit is to follow-up on a plan of correction that was due 11/21/2023. On 11/17/2023 direct care staff Kaydia Sharp emailed LPA Lee training sign in sheet; however, the training sign in sheet is missing staff signatures acknowledging that those staff received training. On 12/06/2023 LPA Lee emailed both direct care staff Kaydia and administrator Mark Labella in regard to (POC) is missing training materials used for the training. On 01/30/2024 at 8:46 AM, administrator Mark emailed LPA Lee training materials that was used during the training on 11/16/2023. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. 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. 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 was provided.the state’s words, verbatim · CDSS document, Jan 30, 2024

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required 1 year annual inspection visit. LPA met with direct care staff and explained purpose of visit. LPA and direct care staff inspected the physical plant including but not limited to the kitchen, dining room, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards. LPA observed sufficient furniture and lighting throughout the facility. LPA observed sufficient seven day non-perishable and two day perishable food supplies. LPA measured the hot water temperature in resident's bathroom at 111.7 degrees Fahrenheit which is within the required range of 105 to 120 degrees. Fire extinguishers last inspected on 9/27/2023. Smoke detectors are operational. LPA observed centrally stored medications are kept locked and inaccessible to clients. LPA reviewed and compared client medication vs. medication logs. First aid kit was checked and is complete. LPA observed carbon monoxide detectors in the facility. The facility conducted fire/disaster drills with residents on 10/1/2023. LPA reviewed six resident files and five staff files, including criminal record clearances. 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. LPA verified staff training for staff file reviews. LPA received the following updated documents on today's date: LIC 308 - Designation of Administrator, Copy of Liability Insurance, and Copy of Administrator Certificate. Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were cited during this visit. Exit interview held with direct care staff. A copy of report and LIC 811 (Confidential Names) were left at facility.the state’s words, verbatim · CDSS document, Jan 10, 2024

Allegation investigated: Staff caused injury to resident in care.

On 11/21/2023 at 10:30 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA Lee met with direct care staff, Cleopatra Gardiner and explained the purpose of the visit. The purpose of this visit is to deliver a complaint finding for the allegation above. The current census is 8. 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. A brief interview with conducted. Allegation: Staff caused injury to resident in care It was alleged that the staff caused injury to a resident in care. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 8 out of 8 residents and 7 out of 8 residents have not witnessed facility staff causing injury to (R1). Moreover, 8 out of 8 residents stated they have no concerns regarding facility staff and do feel safe in the home. Based on staff interviews, staff (S1 ) denied pushing (R1) or any residents. Continued LIC 9099-C Unsubstantiated Moreover, (S2) and (S3) also denies witnessing (S1) pushing (R1) causing injury. Therefore, there is not a preponderance of evidence to prove that facility staff caused injury to resident in care. 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, Nov 21, 2023 · control 27-AS-20231023155603

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 11/13/2023 at 11:05 AM to conduct an unannounced Plan of Correction (POC) visit. LPA Lee was greeted by care staff, Cleopatra Gardiner and explained the purpose of today visit. The current Census is 6 with 2 staff present in the facility. The purpose of this visit is to follow-up on a plan of correction that was due 10/31/2023 and 11/09/2023. Care staff, Kaydia Sharp sent pictures and statement of acknowledgement of POC on 11/08/2023. LPA Lee toured and inspected the facility to ensure the deficiency previously cited on 10/26/2023 have been corrected. Licensee agreed to keep the facility floor plan as licensed. LPA Lee observed care staff moved back to room #10 and room #4 is for resident to reside in. LPA reviewed staff criminal record clearances and a review of staff records indicates that all facility staff or other individuals who require caregiver background checks are fingerprint cleared and associated to the facility. Based upon this inspection, LPA Lee observed the following: 1. Deficiency cited under Title 22 Regulation 87465(a)(4) has not been cleared. The license did not complied with the terms of the POC by POC due date 10/31/2023. A POC letter was not generated and provided to the licensee. 2. Deficiency cited under Title 22 Regulation 87211(a)(1) been cleared. The license complied with the terms of the POC by POC due date. 3. Deficiency cited under Title 22 Regulation 87506(a) been cleared. The license complied with the terms of the POC by POC due date. 4. Deficiency cited under Title 22 Regulation 87309(a) been cleared. The license complied with the terms of the POC by POC due date. 5. 4. .Deficiency cited under Title 22 Regulation 87208(a)(7)(A) been cleared. The license complied with the terms of the POC by POC due date. Continued LIC 809-C The administrator did not complied with the terms of the POC by POC due date 10/31/2023. Exit interview conducted and a copy of this report provided. As a result of this annual visit, the facility is not in compliance with Title 22 Regulation, and the deficiencies can be found on the LIC 809 D page. An exit interview was conducted, and a copy of these LIC 809 reports, LIC 809-D page, and Appeals rights were provided to the facility.the state’s words, verbatim · CDSS document, Nov 13, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(4) · Plan of correction due date: Nov 21, 2023

87465(a)(4) Incidental Medical and Dental Care...A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self administered medications as needed. This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was correct. Resident’s medications did not match up with the Start date of when the resident started their medication; therefore, it is unclear if resident received their medications This posed a health immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Nov 13, 2023

Plan of correction: Administrator agrees to conduct a medication audit and conduct a staff training on proper medication administration procedure. Administrator agrees to email POC to LPA Lee at pang.lee@dss.ca.gov by POC date 11/21/2023. Administrator agrees to send training documents used and sign-in sheet to LPA Lee by POC date 11/21/2023 by end of day.

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Pang Lee arrived at this facility unannounced on 10/26/2023 at 8:00 AM to conduct a case management visit. LPA Lee met with direct care staff Kaydia Sharp and Cleopatra Gardiner and explained the purpose of the visit. Approximately around 8:45 AM, administrator, Mark Labella arrived at the facility. LPA Lee spoke with administrator regarding the purpose of today visit and the deficiencies observed on 10/25/2023. At 10:03 AM, LPA Lee toured the facility and reviewed staff and resident files. The purpose of the visit is to follow up on deficiencies learned during complaint investigation 27-AS-20231023155603. Through the complaint investigation, it was learned that the facility did not follow its plan of operations. The licensee did not ensure to follow the facility sketch. Through observations and interviews it was learned that on 10/22/2023, the facility two live in staff moved and resided in a resident room #4 and a resident, then was moved to the staff room #10. Furthermore, the licensee did not submit this change to the department for approval. At 12:29 PM, LPA Lee observed a Lysol All Purposed Cleaner in a bathroom #2 unlocked. At 12:38 PM, LPA Lee observed another Lysol All Purposed Cleaner on top of the dining table while two residents was eating lunch. LPA Lee also observed another Lysol All Purposed Cleaner in the resident main bathroom counter made accessible to residents in care. At 1:23 PM, LPA Lee requested resident 1 (R1) file for reviewed. It was learned that the following documents were not filled out and left blank; however, the documents had both facility staff and resident signature: LIC 603A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan. Continued- LIC 809-C On 10/24/2023, via telephone, LPA Lee spoke to administrator, Mark Labella in regards to the facility LIC 500 Personnel Report. Per facility LIC 500 it states that administrator will be at the facility from Monday to Thursday from 10:00 AM to 3:00 PM. Administrator confirms that he is not always at the facility during facility hours on the LIC 500. LPA Lee has been out to this facility on 10/25/2023, 10/24,2023, 10/05/2023, 10/20/23, 10/05/2023, 09/26/2023, 09/12/2023 and 06/06/2023 and during all these visit LPA Lee has not seen administrator Mark Labella in the facility per LIC 500. Furthermore, LPA Lee interviewed 10 out of 10 residents who stated that they did not know who the administrator was and have not seen the administrator in the facility. It was also learned through interviews with two outside agency who confirmed with LPA Lee that the administrator is hardly at the facility. During today’s visit LPA Lee reviewed facility unusual incident reports (UIR). It was learned that the facility had documentations in the facility of (UIR). Records reviewed show that the facility had 6 (UIR) for the month of October 3 (UIR) for the month of September, and 3 (UIR) for the month of August; however, LPA Lee reviewed the department Electronic Facility Files, and it was learned that there was no documentation of any (UIR) reported to the department for the month of August, September, and October; therefore, the facility is not following reporting requirements. Moreover, when LPA Lee question administrator, Mark Labella he was not able to give LPA Lee sufficient reason or proof that all these (UIR) has been faxed and reported to the department. 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, Oct 26, 2023

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87405(a) · Plan of correction due date: Nov 2, 2023

87405(a) Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours… This requirement is not met as evidenced by: Based on interviews, records review and observations, the licensee did not comply with the section cited above. The licensee did not ensure that administrator is at the facility for sufficient number of hours, which poses/posed a potential health, safety or personal rights to person in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: Administrator agrees to read regulation 87405(a) and submit a signed declaration of understanding. The administrator will review LIC 500 Personnel Report for accuracy and ensure the administrator is present at the facility for a sufficient number of hours. The administrator will email POC to LPA Lee by POC due date 11/02/2023 by 5:00 PM end of day.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87208(a)(7)(A) · Plan of correction due date: Nov 2, 2023

87208(a)(7)(A) Plan of Operation a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: (7) Sketches, showing dimensions, of the following: (A) Building(s) to be occupied, including a floor plan that describes the capacities of the buildings for the uses intended and a designation of the rooms to be used for non ambulatory residents and for bedridden residents, other than for a temporary illness or recovery from surgery as specified in Sections 87606(d) and (e) This requirement is not met as evidenced by: Based on observations and interview this requirement was not met evidence by: The administrator did not ensure the facility maintained a current plan of operation. The administrator allowed two care staff to reside in a resident room. Licensee did report any room changes and did not maintain a current plan of operation by not updating facility sketch and did not submit changes to CCLD. This posed a potential risk to residents in care. and therefore, another resident was moved to reside in care staff room, which poses/posed a potential health, safety, or personal rights to person in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: The administrator agrees to email updated facility sketch and request approval for plan of operation changes. The administrator agrees to review the regulation being cited today and write a statement acknowledging administrator understand the regulation being cited and email POC to LPA Lee at pang.lee@dss.ca.gov by POC Date 11/02/2023 by end of day 5:00 PM.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Nov 2, 2023

87211(a)(1) Reporting Requirements a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. This requirement is not met as evidenced by: Based on file review and interviews the Licensee did ensure staff were meeting reporting requirements and submitting LIC 624 Unusual incident reports that include elder abuse within 24 hours to CCLD. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: The administrator agrees to read the regulation being cited today and submit a signed declaration of understanding. The administrator will also train all facility staff in regards to the regulation being cited today and provided LPA Lee documents used for the training. The administrator will also provide LPA Lee a staff sign in sheet. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by 11/09/2023 by end of day 5:00 PM

From the deficiency page — Deficiency type: Type B · Section cited: CCR87506(a) · Plan of correction due date: Nov 2, 2023

87506(a) 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 was not met as evidence by: Based on observations and interview administrator did not ensure that resident 1 (R1) It was learned that the following documents were not filled out and left blank with facility staff and resident signature: LIC 603 A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan. The administrator did not ensure a separate and complete current record was maintained for (R1). This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: The administrator agrees to provide training on resident records. Administrator write a statement of declaration of the regulation cited and provide LPA Lee documents used for staff training along with training sign in sheet. The administrator will also write a statement acknowledging and understanding the regulation being cited today. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by POC date 11/09/2023 by end of day 5:00 PM. On 10/25/2023 at 7:38 PM, care staff Kaydia Sharp emailed LPA Lee updated LIC 603 A Resident Appraisal, LIC 601 Identification and Emergency Information, and LIC 625 Appraisal/Needs and Service Plan for resident 1 (R1).

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87309(a) · Plan of correction due date: Nov 2, 2023

87309(a) Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met as evidence by: Based on observation, Administrator did not ensure that Lysol All Purpose Cleaner was made accessible to residents in care, which This poses a potential health and safety risk to persons in care. This posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 26, 2023

Plan of correction: The administrator agrees to provide training on Storage space regulation and provide LPA Lee documents used for staff training along with training sign in sheet. The administrator will also write a statement acknowledging and understanding the regulation being cited today. POC will be emailed to LPA Lee at pang.lee@dss.ca.gov by POC date 11/09/2023 by end of day 5:00 PM.

Allegation investigated: Staff not keeping facility free of pests. Staff not keeping facility free from odor.

On 10/24/2023 at 8:05 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with Direct Care Staff Kaydia Sharp and Cleopatra Gardiner 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 13 with three facility staff. A brief interview were conducted with both caregivers Kaydia and Cleopatra. Administrator Mark Labella was not present during today visit. Allegation: Staff not keeping facility free of pests. It was alleged that staff are not keeping the facility free of pests. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents who have no concern with the facility having pests or roaches. 10 of 10 residents also shared that they have not witnessed any roaches or pests in the facility and in their room. LPA Lee conducted a complaint follow-up investigation on 09/12/2023, 09/26/2023, 10/05/2023 and 10/20/23 and LPA Lee did not observe any roaches or pests in the facility. Continued LIC 9099-C Unsubstantiated It was learned that (R1) had medication for Quetiapine Fumarate, 25 MG and the medication was not on (R1) MAR sheet; therefore, it is unclear if (R1) received the medication. The investigation also revealed that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was incorrect when LPA Lee and care staff Kaydia and Cleopatra counted the residents’ medications. Resident’s medications did not match up with the Start date of when the resident started the medication; therefore, it is unclear if resident received their medications. It was also learned that on the LIC 622 CSMDR medication start date is not filled out correctly. Care staff Kaydia had to call the pharmacy to determine the start date for 3 out 4 resident medications. Per administrator, Mark Labella and both care giver Kaydia and Cleopatra stated that administrator, Mark Labella come to the facility once a week to audit medication; however on 10/05/2023 3 out of 4 residents medication had discrepancy. 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. An exit interview was conducted with Kaydia and Cleopatra and a copy of this LIC 9099, LIC 9099-D page and appeal rights was provided to facility. Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free of pests. Allegation: Staff not keeping facility free from odor. It was alleged that staff are not keeping the facility free from odor. This investigation consisted of records reviewed, observations and interviews with staff and residents. LPA Lee interviewed 10 out of 10 residents who have no concern with the facility having an odor. 10 of 10 residents also shared that they have not witnessed any odor in the facility and in their room. LPA Lee conducted a complaint follow-up investigation on 09/12/2023, 09/26/2023, 10/05/2023 and 10/2023 and LPA Lee did not observe the facility to be odorous. Furthermore, during these complaint follow-up visit, LPA Lee observed facility staff sweeping, mopping, doing the dishes and laundry. Based on information provided through interviews, records reviewed and observation, the allegation is deemed UNSUBSTANTIATED although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation staff not keeping facility free from odor. An exit interview was conducted with both care staff Kaydia and Cleopatra and this report was given to the facility at the end of the visit.the state’s words, verbatim · CDSS document, Oct 24, 2023 · control 27-AS-20230929123535

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Oct 31, 2023

87465(a)(4) Incidental Medical and Dental Care...A plan for incidental medical and dental care shall be developed by each facility...The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidence by: Based on observation and file review, the Licensee did not ensure that 3 out of 4 residents LIC 622, Centrally Stored Medication and Destruction Record (CSMDR) was correct. Resident’s medications did not match up with the Start date of when the resident started their medication; therefore, it is unclear if resident received their medications This posed a health immediate safety risk to residents in care.the state’s words, verbatim · CDSS document, Oct 24, 2023

Plan of correction: Administrator agrees to conduct a medication audit and conduct a staff training on proper medication administration procedure. Administrator agrees to email POC to LPA Lee at pang.lee@dss.ca.gov by POC date 10/31/2023. Administrator agrees to send training documents used and sign-in sheet to LPA Lee by POC date 10/31/2023 by end of day.

Allegation investigated: Staff drugged residents’ food or drinks while in care.

On 10/20/2023 at 11:15 AM, Licensing Program Analyst (LPA) Pang Lee arrived unannounced to this facility to conduct a complaint visit. LPA met with direct care staff, Kaydia Sharp and Cleopatra Gardiner 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 13 with three facility staff. Administrator Mark Labella was not present in the facility during today vist. A brief interview with conducted with both care giver, Kaydia Sharp and Cleopatra Gardiner. Allegation: Staff drugged residents’ food or drinks while in care. It was alleged that the staff drugged residents’ food or drinks while in care. This investigation consisted of records reviewed, interviews with staff, residents, Ombudsman and resident 1 (R1)’s psychiatrist. LPA Lee interviewed 7out of 8 residents who have no concern in regards to staff drugging residents’ food and drink. Throughout the course of the investigation, it was learned that (R1) psychiatrist stated (R1) received a point of care test at the hospital on 08/29/2023. Continued LIC 9099-C Unsubstantiated The test showed that (R1) tested positive for methamphetamine and that it was possible for (R1) medications, Zyprexa, that (R1) is prescribe to potentially cause (R1) to have a false-positive test for methamphetamine. The investigation also revealed that (R1) denies that the facility staff is drugging (R1). 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 allegation is unsubstantiated. There are no deficiencies noted or cited per California Code Regulation, TITLE 22. Exit interview was conducted with the facility staff and a copy of this report was left with care staff Kaydia Sharp..the state’s words, verbatim · CDSS document, Oct 20, 2023 · control 27-AS-20230907092938

Type of visit: POC

Licensing Program Analyst (LPA) Pang Lee arrived at the facility on 10/20/2023 at 10:35 AM to conduct an unannounced Plan of Correction (POC) visit. LPAs Lee met with direct care staff, Kayia Sharp and explained the purpose of the visit. The purpose of this visit is to follow-up on plan of corrections that were due on 10/03/2023. During today's visit, LPA Lee toured and inspected the facility to ensure all deficiencies previously cited have been corrected. The census is 13 with three care staff. Administrator, Mark Labella was not present during today visit. Based upon this inspection, the LPA observed the following: I. Deficiency cited under Title 22 Regulation 87202 has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to the licensee. II. Deficiency cited under Title 22 Regulation 87202(a) has been cleared. Licensee complied with the terms of the POC by POC due date. A POC letter was generated and provided to care staff, Kaydia Sharp. An exit interview was held, and a copy of this report LIC 809, was given to direct care staff, Kaydia Sharp at the end of the visit.the state’s words, verbatim · CDSS document, Oct 20, 2023