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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 05/15/2025
Date Signed: 05/15/2025 10:50:46 AM

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
04/28/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250428155423
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: 40DATE:
05/15/2025
UNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Administrator, Jose AcumabigTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Licensee does not ensure safe pathways are provided for residents use
Staff does not ensure elevators are made accessible for residents at all times.
INVESTIGATION FINDINGS:
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On May 15, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Jose Acumabig and explained the purpose of the visit.

Regarding the allegation, Licensee does not ensure safe pathways are provided for residents use, according to the reporting party, the facility is currently undergoing construction and the walk path that is available for use has uneven pavement and bricks on the ground making it difficult for residents who are disabled and require wheelchair access.

During the investigation, LPA toured the outdoor passageway at the facility that residents use to come into the facility and leave the facility. LPA observed uneven pavement, uneven bricks, and overgrown greenery on the side of the walk way.

Regarding the allegation, staff does not ensure elevators are made accessible to residents at all times, according to the reporting party, the staff are not tending to the service elevator for residents in wheelchairs and walkers in a timely manner to help them get to the areas of the facility. (continue to 9099C).



Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
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-20250428155423
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: 05/15/2025
NARRATIVE
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During the investigation, LPA interviewed staff and residents. According to the administrator, the elevator service being used currently during construction requires a key to get inside and/or outside the facility. According to staff interviewed, depending on the day and time, it may take staff longer to get to the elevator to assist residents, however all residents have access to the elevators. Based on the residents interviewed, there have been several times where it's taken staff more than 10 minutes to open the elevators to go inside and/or outside the facility causing residents to miss their appointments and/or sit in their cars.

Based on the interviews conducted and information collected, 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 Administrator, Jose Acumabig and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20250428155423
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: 05/15/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/16/2025
Section Cited
CCR
87307(d)(6)
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87307 Personal Accommodations and Services: (d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This regulation is not met as evidenced by:
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Licensee/administrator to submit a plan in writing giving CCLD a timeline in which the passageways will be fixed. Plan shall include; company being hired to fix the passageway and timeframe.
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Based on observations, LPA observed uneven pavement, uneven bricks, and overgrown greenery on the side of the walk way which poses an immediate health and safety risk to residents in care.
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Type B
05/22/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General:
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...

This regulation is not met as evidenced by:
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Licensee/administrator shall conduct an in-service training with staff to ensure response times are reduced.

Additionally, Administrator purchased 5 more elevator keys for residents to use when leaving the facility.
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Based on staff interviews, it was acknowledged that depending on the day and time, it may take staff longer to get to the elevator to assist residents. Based on the residents interviews, there have been several times where it's taken staff more than 10 minutes for staff to open the elevators to go inside and/or outside the facility causing residents to miss their appointments and/or sit in their cars.
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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: 05/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3