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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 09/29/2023
Date Signed: 09/29/2023 01:12:32 PM


Document Has Been Signed on 09/29/2023 01:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:JOAN JOHNSONFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 0DATE:
09/29/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Resident Care Director, E. DewittTIME COMPLETED:
01:30 PM
NARRATIVE
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On September 29, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a letter that was received from state official. LPA met with Resident Care Director, E. Dewitt and explained the purpose of the visit.

On September 24, 2023, the Department was notified by the state official of a letter that was sent to Resident 1 (R1) in regards to potential eviction due to non-compliance. R1 has been a resident at Vista Terrace of Belmont prior to the emergency evacuation.

LPA requested copies of R1's signed admission agreement, physician's report, care plan, however according to interviewed staff, R1's file has been misplaced and no where to be found. In addition, it was indicated that R1 does not have a signed admission agreement. According to Resident Care Director, R1 refused to sign the admission agreement. R1's physician's report was observed to be dated 12/20/2021.

According to the Resident Care Director a care conference was held on 4/19/2023, with R1, R1's family member, administrator, resident care director, and ombudsman regarding R1's care concerns and R1 was to call his/her PCP to schedule a physical on 4/21/2023 or 4/24/2023. Resident Care Director indicated R1 did not schedule the physical due to the emergency evacuation on 4/28/2023.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Resident Care Director. A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 09/29/2023 01:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
87507(c)

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87507 Admission Agreement: (c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission...

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator shall submit a written plan to ensure facility maintains signed and dated copies of admission agreements for each resident.
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Based on record review, facility failed to maintain a copy of a signed and dated admission agreement for R1 prior to admission at Vista Terrace of Belmont.
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Type B
10/06/2023
Section Cited
CCR87506(a)

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87506 Resident Records: 87506 Resident Records: (a) The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit a written plan in writing describing how facility will ensure complete and current resident records are maintained as indicated on CCR 87506
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Based on record review and staff interviews, facility misplaced R1's file and are unable to provide R1's records (admission agreement, pre-appraisal, care plan) to licensing staff when R1 was residing at Vista Terrace of Belmont, prior to the emergency evacuation
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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 09/29/2023 01:12 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 09/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2023
Section Cited
CCR
87458(a)

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87458 Medical Assessment :
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator to submit a plan in writing regarding how to ensure residents will follow up with their PCP is there is a change of condition or if a new physician's report is needed.
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Based on record review, R1's physicians report is dated 12/20/2021 and R1 had a change in condition that was discussed during a care conference on 4/19/2023. Nevertheless, the facility failed to ensure R1's physician's report was current.
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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.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2023
LIC809 (FAS) - (06/04)
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