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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 02/27/2025
Date Signed: 02/27/2025 01:44:30 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/25/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250225152851
FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:KAITLYN CLAREYFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 31DATE:
02/27/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Culinary Service Director, Justin KangTIME COMPLETED:
01:55 PM
ALLEGATION(S):
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Facility staff did not dispense medications as prescribed
INVESTIGATION FINDINGS:
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On February 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Culinary Service Director, Justin Kang and explained the purpose of the visit.

Regarding the allegation, facility staff did not dispense medications as prescribed, according to the reporting party, Resident 1 (R1) supposed to receive his/her Carbidopa Parkinson’s medication between 6am-6:30am every morning before breakfast, however on 2/25/25, R1 did not receive his/her medication as prescribed because there was med-tech working to dispense his/her medication. R1 did not receive his/her Carbidopa medication until 8:45am.

During the investigation, LPA interviewed the nurse that was on shift in the morning of 2/25/25, reviewed R1’s medications and reviewed R1’s medication administration record (MAR). According to the nurse, the AM med-tech did not show up for work and he/she had to go to the facility to give residents their medications. In addition, the nurse indicated that she did not get to the facility till about 8:15am-8:30am and immediately provided R1 his/her medication. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 14-AS-20250225152851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: VISTA TERRACE OF BELMONT
FACILITY NUMBER: 415601080
VISIT DATE: 02/27/2025
NARRATIVE
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Based on R1's medications reviewed and the MAR, R1 is prescribed to take two tabs of Carbidopa-Levodopa by mouth four times daily at 6am, 10am, 2pm, and 6pm. Based on the MAR, on 2/25/25, R1 was not given his/her Carbidopa medications on time in the morning, as R1 received his/her Carbidopa medication at 8:24am and the second round at 11:15am.

Based on the information collected, and records reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Culinary Service Director, Justin Kang and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20250225152851
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VISTA TERRACE OF BELMONT
FACILITY NUMBER: 415601080
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/27/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/28/2025
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care: (a) A plan for incidental medical and dental care shall be developed by each facility... (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan in writing on how to ensure residents receive their medication based on their doctor's orders. Plan shall include training staff and hiring more staff if necessary.
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Based on R1's medication reviewed and the MAR reviewed, R1 was supposed to be given Carbidopa at 6am and 10am, however was not given the medications until 8:24am and 11:15am which poses an immediate health and safety risk for residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3