415601080-10-24-2023-14-AS-KHOS-CXAVJF-20231105152840

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 10/24/2023
Date Signed: 10/24/2023 12:42:37 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
10/02/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231002160539

FACILITY NAME:	VISTA TERRACE OF BELMONT		FACILITY NUMBER:	415601080
ADMINISTRATOR:	JOAN JOHNSON		FACILITY TYPE:	740
ADDRESS:	900 SIXTH AVENUE		TELEPHONE:	(650) 591-2008
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	68	CENSUS: 0	DATE:	10/24/2023
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	Administrator, Joan Johnson		TIME COMPLETED:	12:55 PM

ALLEGATION(S):

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Staff are not ensuring resident has privacy
Staff are discriminating against resident
Staff did not ensure resident's room was free of pest

INVESTIGATION FINDINGS:

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On October 24, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Administrator, Joan Johnson and explained the purpose of the visit.

Regarding the allegation staff are not ensuring resident has privacy, according to the reporting party, staff are entering into Resident 1's (R1's) room without permission. According to the reporting party, R1 is germaphobic and does not want anyone to enter his/her room. In addition, according to the reporting party, an agency staff member (name not identified) entered R1's room without knocking and was staring at R1's shower curtain while R1 was taking a shower.

During the investigation, LPA interviewed staff and reviewed records. According to staff interviewed, staff respects R1's wishes and does not go into his/her room unless R1 allows staff to enter. In addition, interviewed staff acknowledged that the facility did use agency caregivers and they were not aware of R1's phobias, however facility administrator at the time tried to instruct all staff members to knock/ring R1's door prior to entering to respect his/her request.

Based on Belmont Police Incident Report reviewed, R1 advised staff to come in and check on him/her, however the agency caregiver went into R1's room while R1 was in the shower, apologized and immediately walked outside. According to the Incident Report, R1 was concerned that the new staff was bringing germs into his/her room. (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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20231002160539

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: 10/24/2023

NARRATIVE

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Regarding the allegation that staff are discriminating against resident, according to the reporting party, Resident 1 (R1) is being discriminated against for standing up and eating and was told she can’t be in there if he/she is standing. During the investigation, LPA interviewed staff. Administrator denied this allegation and indicated that no staff has told R1 that he/she can't eat in the dining room if he/she is standing. Based on staff interviews, residents addressed to administrator that they were uncomfortable eating because R1 would be standing and eating in the dining room with his/her back towards residents, and would wear a garbage bag.

Regarding the allegation that staff did not ensure resident's room was free of pests, according to the reporting party, the facility failed to ensure pests/flies were not in Resident 1's (R1's) room as R1 has OCD and is germaphobic.

During the investigation, LPA was unable to tour and observe R1's room due to facility closure, however LPA interviewed staff. According to 3/3 staff interviewed, R1 has OCD, is germaphobic and hoards items in his/her room. Staff interviewed indicated that R1 would not allow any staff to come into his/her room, including housekeepers due to his/her phobias. In addition, according to interviewed staff, when R1 addressed the flies/pests issue to management, ECO-Lab was notified immediately and they came on a regular basis to inspect the facility. Due to R1's phobias, R1 did not let anyone in his/her apartment to inspect or treat the alleged pests.

Based on the interviews conducted, record review, 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 Administrator, Joan Johnson 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: 10/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023

LIC9099 (FAS) - (06/04)

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