415601080-7-12-2024-14-AS-AMEN-D7PTKJ-20240731144757

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:50:57 PM

Unsubstantiated

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
06/12/2024 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240612121234

FACILITY NAME:	VISTA TERRACE OF BELMONT		FACILITY NUMBER:	415601080
ADMINISTRATOR:	PEPER, DAVE		FACILITY TYPE:	740
ADDRESS:	900 SIXTH AVENUE		TELEPHONE:	(650) 591-2008
CITY:	BELMONT	STATE: CA	ZIP CODE:	94002
CAPACITY:	68	CENSUS: 24	DATE:	07/12/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Douglas Blake & Nelsa Alferos		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff did not assist resident with toileting

INVESTIGATION FINDINGS:

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On 7/12/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Douglas Blake & Resident Care Coordinator Nelsaand explained the purpose of today's visit.

Regarding the allegation of staff did not assist resident (R1) with toileting, Reporting Party (RP) stated that R1 called for staff to come help to the bathroom during the night and no one would come.

Based on records review, the pendant or call buttons pressed by the R1 was all answered by staff. The log reviewed were from March 16 to June 26, 2024. It showed that all calls were answered by the staff.

LPA also interviewed ED and Resident Care Coordinator and mentioned that the staff normally does 2-hour intervals for checking on residents. Response time for call buttons is between 2 to 8 minutes.

Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed and copy is provided.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 07/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

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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