415601080-5-1-2024-14-AS-AMEN-D59PPF-20240514112927

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 05/01/2024
Date Signed: 05/01/2024 12:30:33 PM

Substantiated

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
10/23/2023 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20231023131617

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: 19	DATE:	05/01/2024
		UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Michelle Baker		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Facility failed to ensure residents received hot water prior to emergency evacuation
Facility failed to provide sufficient staffing to meet residents needs

INVESTIGATION FINDINGS:

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On May 1, 2024, Licensing Program Analyst (LPA) John Calandra conducted a conclusionary complaint investigation at the facility and met with Michelle Baker, Business Office Director. The purpose of the visit was to deliver conclusionary findings to the initial complaint investigation on October 31, 2023. LPA gathered information relevant to the above complaint allegations and interviewed staff and residents. Regarding the allegation that residents did not have hot water prior to an emergency evacuation, based on interviews, it was determined to be true that residents had lost access to hot water after the power outage.

In regards to the allegation of insufficient staffing to meet the needs of residents, it was determined to be true based on conducted interviews. During the time of the power outage, there was not enough staff to meet residents’ needs.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

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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Control Number 14-AS-20231023131617

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: 05/01/2024

NARRATIVE

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The Department has investigated the above complaint allegations of a possible violation of a resident’s personal rights and insufficient number of staffing to meet the resident needs. Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegations are determined to be substantiated. The deficiencies cited on the following pages are in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8: Maintenance and Operations and Personnel Requirements-General

This report is provided and reviewed with facility representative and a copy of this report must be made available for public review upon request. Appeal rights discussed and provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20231023131617

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: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type B 05/10/2024 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411(a): Personnel Requirements-General: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.	1 2 3 4 5 6 7	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
	8 9 10 11 12 13 14	Based on interviews with residents, the Licensee did not comply with this requirement in 1 out of 1 instances, in which the facility did not have enough staff to meet residents' needs, which poses/posed a potential health, safety or personal rights risk to persons 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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20231023131617

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: 05/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/02/2024 Section Cited CCR 87468.2(a)(4)	1 2 3 4 5 6 7	87468.2(a)(4): Additional Personal Rights of Residents in Privately Operated Facilities a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:	1 2 3 4 5 6 7	Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
	8 9 10 11 12 13 14	(4) To care, supervision, and services that meet their individual needs. The licensee did not comply with the section cited above in 1 out of 1 instances in which residents did not have access to hot water prior to an emergency evacuation, which poses an immediate health, safety or personal rights risk to persons 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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 05/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/01/2024

LIC9099 (FAS) - (06/04)

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