415601080-3-27-2024-14-AS-KHOS-D3XGRM-20240402053433

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 03/19/2024
Date Signed: 03/27/2024 04:15:46 PM

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
03/15/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240315135733

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: 13	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Administrator, Kaitlyn Clarey		TIME COMPLETED:	01:20 PM

ALLEGATION(S):

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-Facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services

INVESTIGATION FINDINGS:

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On March 27, 2024, Licensing Program Analyst (LPA) Komal Charitra delivered an amended copy of the LIC9099. LPA met with Co-administrator, Douglas Blake and explained the purpose of the visit. During visit today, LPA changed the report from confidential to public. Report is reviewed with Co-administrator and a copy is provided.

On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra delivered a copy of amended LIC9099. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit.

On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit.

Regarding the allegation, facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services, according to the reporting party, facility has old medication stored for clients who no longer reside at the facility and/or are expired.

During the visit, LPA interviewed administrator, facility staff and observed medication room. According to administrator, she acknowledged this allegation and indicated that when the facility reopened back in January 2024, she was unable to get the third-party waste company to come to the facility to pick up the medications, however due to unpaid invoices from previous management, the waste company provider did not come to the facility. A new medical waste company was contacted and contract was signed as of March 4, 2024 to pick up the expired medication an as of March 4, 2024.

Continue 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: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

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 3

Control Number 14-AS-20240315135733

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: 03/19/2024

NARRATIVE

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During the visit, LPA observed medication room on the first floor to be locked and inaccessible to clients. LPA observed a locked cabinet with expired medications and medications for residents who no longer reside at the facility.

Based on interviewed staff, the expired medications and medications for residents who no longer reside at the facility has been at the facility since they've reopened back in January 2024. Staff indicated they notified the Regional Health and Wellness Director, Blanca Hurtado and the administrator, however they were unsure why the medications were not disposed of immediately after notifying them.

Therefore, the allegation facility staff do not properly dispose of medications which were not taken with the resident(s) upon termination of services is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrator and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20240315135733

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: 03/19/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/20/2024 Section Cited CCR 87465(i)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of… shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following... Violation of this regulation is not met as evidenced by:	1 2 3 4 5 6 7	Facility administrator and another facility staff took the medication to a drop box at CVS pharmacy and provided LPA a copy of the medication destruction log.
	8 9 10 11 12 13 14	Based on observations, LPA observed expired medication and medications for residents who no longer reside at the facility in a locked cabinet in the medication room. In addition, based on interviews conducted, facility staff were aware of the medications that should've been disposed since the facility reopened in January 2024.	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: 03/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2024

LIC9099 (FAS) - (06/04)

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