415601080-7-17-2024-14-AS-AMEN-D83T9Q-20240812143217

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 07/12/2024
Date Signed: 07/17/2024 02:20:50 PM

Unfounded

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
05/30/2024 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240530100108

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:	01:25 PM
MET WITH:	Douglas Blake & Nelsa Alferos		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not dispense medications as prescribed

INVESTIGATION FINDINGS:

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*** This is an amended report ***

On 7/16/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Executive Director Douglas Blake and explained the purpose of today's visit.

Regarding the allegation facility staff did not dispense medications as prescribed, Reporting Party (RP) stated that staff do not dispense medications as prescribed to resident (R1). Per RP, on Tuesday 5/28/24 the resident was given a yellow pill with his morning meds (6am). R1 knew he/she doesn't normally take a yellow pill so he/she told the staff who immediately told him/her not to take it because the pill was given in error.

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Unfounded

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)

Page: 1 of 4

Control Number 14-AS-20240530100108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VISTA TERRACE OF BELMONT	FACILITY NUMBER: 415601080
	VISIT DATE: 07/12/2024

NARRATIVE

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LPA reviewed medication records and it was found out that the medication that is needed to be taken on specific time and interval were not given accordingly on both months of February and March of 2024, the medication were administered on the following times, 2 tablets every 6:30am, 12:00pm, 6:00pm. Having an interval of 4.5 hours to 6 hours. There were no doctors’ orders specific to the time that the medication needs to be given. All that was provided was that it needs to be administered 3x/day. LPA was able to obtain a copy of the order but was dated 4/10/2024. This has been followed upon receiving this order. The medication administration record since April already reflected that it is given at 6am, 11am & 5pm.

LPA was also able to interview R1s physician (DR). DR confirmed that the medication should be taken every five hours and that based of the medication orders given it should be at taken at 6am,11am & 5pm. LPA also interviewed a staff (S1) and It was stated that the yellow pill mentioned is an order for daily aspirin, in the morning. That tablet is in fact small and pale yellow in color. During the interview S1 stated that there were no discrepancies, errors, refusals, or conversations about the medications as they were given as prescribed the morning of the 28th.

LPA also observed one of the medications for R1 as having a pale yellow in color.

Based on interviews and observations, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
05/30/2024 and conducted by Evaluator Grace Donato

COMPLAINT CONTROL NUMBER: 14-AS-20240530100108

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:	01:25 PM
MET WITH:	Douglas Blake & Nelsa Alferos		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff did not discuss resident reappraissal to responsible party

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 and explained the purpose of today's visit.

Regarding the allegations of Facility staff did not discuss resident reappraisal to responsible party. RP stated that they have been asking for several months for a copy of the resident appraisal from January 2024 when R1 moved into the facility and staff have not provided it.

Based on records review, an email was sent to RP providing the January 2024 assessment on May, 30, 2024.

Based on records review, the department has determined that that the allegations were false, could not have happened and/or is without a reasonable basis, therefore the allegations are UNFOUNDED.

Report is reviewed and copy is provided.

Unfounded

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)

Page: 3 of 4

Control Number 14-AS-20240530100108

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 07/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/13/2024 Section Cited CCR 87465(a)(4)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...(4) The licensee shall assist residents with self-administered medications as needed.	1 2 3 4 5 6 7	Licensee has already corrected this and has been giving time sensitive medications on time.
	8 9 10 11 12 13 14	This was not met as evidenced by, based on records review, the medication that needs to be given on a specific time was not administered on time between Ferbruary and March 2024, which poses an immediate health, safety, or personal rights risk to clients in care.	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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2024

LIC9099 (FAS) - (06/04)

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