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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 08/26/2025
Date Signed: 08/26/2025 01:42:19 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
08/13/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250813150601
FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:MICHELLE BAKERFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 51DATE:
08/26/2025
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Regional Sales Specialist, Jessica WigginsTIME COMPLETED:
01:57 PM
ALLEGATION(S):
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Staff are not administering residents' medications as prescribed
Facility failed to report incident to CCLD
Facility failed to ensure resident's beds were in good repair
INVESTIGATION FINDINGS:
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On August 26, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Regional Sales Specialist, Jessica Wiggins and explained the purpose of the visit.

Regarding the allegation, staff are not administering residents' medications as prescribed, according to the reporting party, Resident 1 (R1) is not being administered the correct dosage of his/her Gabapentin medication as prescribed by the physician.

During the investigation, LPA interviewed R1, reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. According to R1, on 8/8/25 and 8/10/25, he/she was supposed to receive 3 tablets of Gabapentin at 8pm, however on both days, only 1 tablet was provided. Resident 2 (R2) noticed and reported to the med-tech that R1 is supposed to receive three tablets of Gabapentin instead. The med-tech fixed the error immediately. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on both days if R2 did not catch this error. (continue to 9099C).
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
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 6
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
08/13/2025 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250813150601

FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:MICHELLE BAKERFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 51DATE:
08/26/2025
UNANNOUNCEDTIME BEGAN:
12:07 PM
MET WITH:Regional Sales Specialist, Jessica Wiggins TIME COMPLETED:
01:57 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not assisting residents with obtaining medical care
Staff are not answering resident's call button in a timely manner
INVESTIGATION FINDINGS:
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5
6
7
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On August 26, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Regional Sales Specialist, Jessica Wiggins and explained the purpose of the visit.

Regarding the allegation, staff are not assisting residents with obtaining medical care, according to the reporting party, Resident 5 (R5) is not getting assistance with getting scheduled for physical therapy.

During the investigation, LPA interviewed staff, R5 and reviewed R5’s file. According to R5, he/she no longer has complaints with getting assistance with obtaining medical care. According to staff interviewed, they were not aware that R5 needed assistance with obtaining medical care for physical therapy.

Regarding the allegation, staff are not answering resident’s call button in a timely manner, according to the reporting party, Resident 6 (R6) is not getting his/her call button answered in a timely manner. (continue to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20250813150601
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: 08/26/2025
NARRATIVE
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During the visit, LPA reviewed R6’s call button response log and interviewed R6. According to R6, staff are responding to his/her call button on time. In addition, R6 indicating that he/she understands and is not complaining when staff take longer to respond at times as staff are assisting other residents. Based on R6’s call button response log, staff do respond timely to R6’s calls.

Based on interviews conducted and information collected, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

Report is reviewed with Regional Sales Specialist, Jessica Wiggins and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20250813150601
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: 08/26/2025
NARRATIVE
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A civil penalty of $250 is issued today for a repeat violation within the last 12 months. The facility has received a deficiency for California Code of Regulations, 87465 Incidental Medical and Dental Care in relation to the med-errors on 2/27/25, 4/29/25, 5/6/25, and 7/1/25.

Regarding the allegation, facility failed to report incident to CCLD, according to the reporting party, the facility is not reporting R1’s med errors to CCLD.

During the visit, LPA reviewed records and interviewed staff. Based on records, it was observed that the facility has not submitted any incident reports to CCLD regarding R1’s med-errors that occurred on 8/8/25 and 8/10/25. According to staff interviewed, they believed that an incident report did not have to be submitted because although the med-errors occurred, it was caught by R2 and fixed by the med-tech.

Regarding the allegation, facility failed to ensure resident's beds were in good repair, according to the reporting party, Resident 3’s (R3’s) and Resident 4's (R4’s) bed collapsed because the maintenance director did not assemble the beds correctly.

During the visit, LPA interviewed staff, R3 and R4. According to R3, he/she was sitting on the side of the bed that was provided by the facility, when the bed's slate underneath the mattress slipped, causing the mattress to collapse on the floor. LPA was unable to interview R4, however according to staff interviewed, they indicated that R4's bed did not collapse, R4 just rolled out of it. In addition, according to staff interviewed, R3's bed was not able to hold his/her weight causing the slate to shift and the mattress to collapse. Although LPA was unable to interview R4, R3's bed was not in good repair, causing R3's bed mattress to collapse.

Based on the interviews conducted, records reviewed 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 Regional Sales Specialist, Jessica Wiggins and a copy is provided with appeal rights. A copy of the civil penalty is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20250813150601
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: 08/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/27/2025
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 will submit a plan in writing on how to ensure med-errors will not keep continuing in the future. Plan shall include, training, audits and the frequency of audits, hiring med-techs.
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Based on interviews and records reviewed, on 8/8/25 and 8/10/25 at 8pm on both days, R1 was administered only one tablet of Gabapentin instead of three tablets by the med-tech. R2 caught the error and notified the med-tech who fixed the error. Although this incident was caught by R2 and fixed by the med-tech, the med-tech would have administered one tablet of Gabapentin to R1 at 8pm on both days if R2 did not catch this error which poses an immediate health and safety risk to residents in care.
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A civil penalty of $250 is assessed today for a repeat violation within the last 12 months. Facility was cited for the same deficiency on 2/27/25, 4/29/25, 5/6/25 and 7/1/25.
Type B
09/02/2025
Section Cited
CCR
87211(a)(1)
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87211 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...within seven days of the occurrence of any of the events specified in (A) through (D) below...

This requirement is not met as evidenced by:
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Based on records, it was observed that the facility has not submitted any incident reports to CCLD regarding R1’s med-errors that occurred on 8/8/25 and 8/10/25. According to staff interviewed, they believed that an incident report did not have to be submitted because although the med-errors occurred, it was caught by R2 and fixed by the med-tech. This poses a potentional health and safety risk to residents in care.
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Licensee/administrator shall review CCR 87211 Reporting Requirements and submit acknowledgement that regulation has been reviewed.
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: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20250813150601
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: 08/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/02/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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Licensee/administrator shall ensure that a proper pre-appraisal is done to ensure that resident's furnishings are equipped and appropriate for them. Licensee/administrator shall submit a plan in writing on how to ensure residents furnishings are in good repair and alternatives options are provided if needed.
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Based on interviews conducted, R3 indicated he/she was sitting on the side of the bed that was provided by the facility, when the bed's slate underneath the mattress slipped, causing the mattress to collapse on the floor. ccording to staff interviewed, R3's bed was not able to hold his/her weight causing the slate to shift and the mattress to collapse which poses a potentional health and safety risk to 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: 08/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6