415601080-9-22-2023-14-AS-KHOS-CW8JS4-20231002071743

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 09/22/2023
Date Signed: 09/22/2023 12:49:41 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/30/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230430171642

FACILITY NAME:	VISTA TERRACE OF BELMONT		FACILITY NUMBER:	415601080
ADMINISTRATOR:	SIOBHAN SURRACO		FACILITY TYPE:	740
ADDRESS:	900 SIXTH AVENUE		TELEPHONE:	(650) 591-2008
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	68	CENSUS: 23	DATE:	09/22/2023
		UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Resident Care Director, Edward Dewitt		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Illegal eviction
-Facility failed to notify family members of emergency situation and relocation
-Facility failed to have an adequate emergency preparedness plan

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On September 22, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Resident Care Director, Edward Dewitt and explained the purpose of the visit.

Regarding the allegation of illegal eviction, according to the reporting party, due to an emergency situation, the facility moved residents without any notice. During the investigation, LPA interviewed the administrator, reviewed facility's plan of operation and and resident admission agreement.

The administrator denied this allegation and indicated that the facility had a disrepair in their electrical system which caused a power outage at the facility. The facility tried to ensure residents were receiving care and supervision with back up generators, however due to the extent of the electrical disrepair and the uncertainty of how long repairs would take, the facility had to relocate residents to their sister facilities.

Based on the resident admission agreement, under the section regarding emergency procedures, the agreement indicated that emergency disaster plans which defines policies and procedures in the event of earthquakes, flooding, power outages, etc. is readily available to residents and family members for review.

Continue to 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 2

Control Number 14-AS-20230430171642

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 09/22/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Regarding the allegation, facility failed to notify family members of emergency situation and relocation, according to the reporting party, the facility did not notify the family members about the power outage when it occurred and the facility did not notify family members about the relocation in a timely manner.

During the investigation, LPA interviewed the Administrator, Resident Care Director, and family members. Both the administrator and resident care director denied this allegation and indicated that as soon as they found out about the relocation, both the administrator and the Resident Care Director started calling family members to notify them of the relocation. According to 4/4 of the families interviewed, the facility notified them immediately after being aware of the relocation.

Regarding the allegation, facility failed to have an adequate emergency preparedness plan, according to the reporting party, the facility did not have a sufficient amount of lanterns and they administrator had to go out and buy lanterns.

During the investigation, LPA interviewed the administrator, resident care director and reviewed facility's emergency preparedness plan. The administrator and resident care director denied this allegation and indicated that the facility had an emergency disaster plan that was kept and adhered to. In addition, it was stated that there were a sufficient amount of lanterns and flashlights for residents, however additional lanterns were purchased to provide residents with additional lighting. Families interviewed indicated that facility tried to ensure residents received necessary supplies to be comfortable at the facility during the power outage.

Therefore, based on the interviews conducted and information collected, the allegations above are UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Resident Care Director and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2