415601080-11-14-2024-14-AS-KHOS-DB5SH9-20241118125308

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 11/14/2024
Date Signed: 11/14/2024 12:30:01 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
11/07/2024 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20241107125642

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: 28	DATE:	11/14/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Kaitlyn Clarey		TIME COMPLETED:	12:45 PM

ALLEGATION(S):

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Staff did not inform residents of planned fire inspection

INVESTIGATION FINDINGS:

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On November 14, 2024, Licensing Program Analyst (LPA) Komal Charitra conduted an unannounced 10-day complaint visit. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit.

Regarding the allegation, staff did not inform residents of planned fire inspection, according to the reporting party, on 11/7/24, the facility conducted some sort of fire drill/inspection at the facility and staff failed to inform and communicate with residents about this matter, resulting in panick and stress.

During the investigation, LPA interviewed administrator, staff and residents. The administrator acknowledged that no notice was provided to the residents. According to the Maintenance Director, this is a yearly fire inspection where outside vendor, Cintas comes to the facility and checks the sprinkler system and fire alarms. The Maintenance Director acknowledged that he was aware that Cintas was going to conduct their inspection for only the sprinkler system on 11/7/24 a few days prior to the scheduled date, however during the inspection, Cintas observed other overdue inspections, including fire alarm. The Maintenance Director admitted he allowed Cintas to continue with all inspections and did not notify the residents prior to allowing Cintas to continue with their inspection.

In addition, based on 4 staff interviewed, they indicated they were not aware the fire inspection drill was going to be conducted on 11/7/24. (continue to 9099C).

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

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-20241107125642

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: 11/14/2024

NARRATIVE

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Furthermore, according to 4/4 residents interviewed, no notification was provided to them and staff did not communicate to them regarding the fire inspection. Residents interviewed indicated that they were scared, nervous, and did not feel safe because the fire alarms were loud and went on for about 20-25 minutes. In addition, residents stated they were not sure what to do as staff did not tell them anything.

Therefore, the allegation staff did not inform residents of planned fire inspection 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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20241107125642

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: 11/14/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/21/2024 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	Licensee/administrator shall submit a plan in writing regarding how to ensure proper communication is provided to all residents regarding the facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: The facility failed to provide residents notification or communicate with residents regarding a fire inspection that occurred on 11/7/24, resulting in residents to feel unsafe, scared, and nervous. According to the Maintenance Director, he was aware that outside vendor, Cintas was going to come to the facility a few days prior and was aware that Cintas was going to test the fire alarms, however admitted that he allowed them to continue and test the alarms without any notification to residents	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: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:	DATE: 11/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2024

LIC9099 (FAS) - (06/04)

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