415601080-5-17-2023-14-AS-CSMH-CS6S4W-20230525133325

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 05/17/2023
Date Signed: 05/17/2023 11:43:59 AM

Substantiated

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
04/27/2023 and conducted by Evaluator Komal Charitra

COMPLAINT CONTROL NUMBER: 14-AS-20230427165107

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: 0	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Adminstrator, Joan Johnson		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility failed to maintain an electrical system in good working condition.

INVESTIGATION FINDINGS:

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On May 17, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the finding for the above allegation. LPA met with Administrator, Joan Johnson and explained the purpose of the visit.

Regarding the allegation, facility failed to maintain an electrical system in good working condition, according to the reporting party, the facility has been out of power since 4/24/2023 and this has been the second time that the facility has had a power failure, as the first time was back in January 2023. In addition, the reporting party indicated that after the January incident, another generator was to be purchased for additional back-up, however it was not purchased and now residents are without power again, leaving rooms cold, residents with no lights and inability to contact caregivers for assistance.

During the investigation, LPA toured the facility and interviewed the Administrator. According to the administrator, the power has been out since 4/24/23, however the facility had called electricians to come to the facility on 4/24/23 after the power went out and 4/25/23. On 4/25/23, the electricians indicated that the master/main breaker was in disrepair and a new part was required. The facility ordered the part and it was to be installed, however the facility and the electricians were unable to install it until PG&E approved the installation.

Although the facility ensured the residents were safe and comfortable during the time the facility had a power outage, the facility failed to ensure that the main electrical system was in good repair after the incident that occurred on January of 2023, when the facility had a power outage for about 3-4 days due to the winter storms, leaving residents with no hot water, no heater, and no lighting in rooms. (CONT. TO 9099C)

Substantiated

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: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-20230427165107

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: 05/17/2023

NARRATIVE

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The administrator provided LPA with an invoice dated 2/6/23 and 2/16/23, indicating that service conducted on 1/11/23 and 1/12/23 by Direct Supply electricians diagnosed the main breaker system as an issue.

The facility failed to have the Maintenance Director and/or electricians check on the electrical systems routinely after having issues with the power and being aware that the breaker system was an issue based on the services conducted in January. Furthermore, the facility failed to ensure the electrical system was in good repair, resulting into an emergency evacuation of all 36 residents to the facility's sister communities on 4/28/23.

The deficiencies for the above substantiated allegations is cited in accordance with California Code of Regulations, Title 22, Division 6 and is noted on attached LIC 9099-D.
Report is reviewed with Joan Johnson and a copy of the report is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230427165107

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Request Denied Type A 05/18/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times.. Maintenance shall include...procedures for the safety and well-being of residents... Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Licensee to develop a plan in writing to address how to repair the main/master breaker. Licensee to submit a timeline in which the electrical system would be repaired
	8 9 10 11 12 13 14	Based on interviews conducted and observations made,although the facility ensured the residents were safe and comfortable during the time the facility had a power outage, the facility failed to ensure that a main electrical system was in good repair after the incident that occurred on January of 2023. an invoice dated 2/6/23 and 2/16/23, indicating that service conducted on 1/11/23 and 1/12/23 by Direct Supply electricians diagnosed the main breaker system as an issue.Furthermore, facility failed to have the Maintenance Director and/or electricians check on the electrical systems routinely after having issues with the power and being aware that the breaker system was an issue.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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