<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 09/16/2025
Date Signed: 09/16/2025 11:06:16 AM

Document Has Been Signed on 09/16/2025 11:06 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR/
DIRECTOR:		JIM SIDOTIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY: 68CENSUS: 55DATE:
09/16/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Jim SidotiTIME VISIT/
INSPECTION COMPLETED:
11:17 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On September 16, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on two incidents that occurred on 8/28/25 and 9/3/25. LPA met with Administrator, Jim Sidoti and explained the purpose of the visit.

On 8/28/25, the Licensee reported that the agency nurse failed to provide Resident 1 (R1) his/her PM medications. During the visit, LPA reviewed R1's file, including but not limited to; physician's orders for medication, medication list, medication administration record (MAR), and R1's medication bottles. Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication. The facility failed to provide R1's medication as prescribed by the physician.

On 9/3/25, the Licensee reported that an agency CNA (S1) was attempting to assist Resident 2 (R2) with changing his/her brief and started rummaging through R2's nighstand drawer. R2 refused assistance and S1 threw R2's pajamas at R2 and told R2 to not call for assistance again. All required parties were notified, including the Belmont Police Department. Regional Sales Specialist, Jessica Wiggins ended S1's shift and immediately walked the S1 out. S1 is no longer allowed in the community.

During the visit, LPA reviewed the facility's internal investigation, attempted to interview R2, discussed the incident with the administrator, and reviewed R2's file. Based on R2's file reviewed, R2 has a diagnosis of Parkinson's Disease. Based on R2's service plan, R1 is independent and does not require assistance with toileting and dressing. According to staff interviewed, although R2 is independent, due to his/her Parkinson's disease, facility staff check in on R2 and offer assistance. Based on the facility's internal investigation, R2 was not missing any personal belongings and R2 was not injured. LPA was unable to interview R2 during the visit. A statement was provided to facility by S1 indicating, he/she was only trying to assist R2 with changing R2's pants and diaper.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. A civil penalty of $1,000.00 is issued today for a repeat violation within the last 12 months for CCR 87465(a)(4). Report is reviewed with the administrator and a copy is provided with appeal rights. A copy of civil penalty is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/16/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 3
Document Has Been Signed on 09/16/2025 11:06 AM - It Cannot Be Edited


Created By: Komal Curley On 09/16/2025 at 10:38 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 09/16/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/17/2025
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... (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee/Administrator shall submit a plan in writing on how to ensure agency med-techs are trained prior to administering medication to avoid med-errors.
8
9
10
11
12
13
14
Based on R1's medication list, R1 is required to receive his/her one 15mg tablet of Mirtazapine daily at 8:00pm, however the facility did not provide R1 his/her medication as prescribed by the physician which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
A civil penalty of $1,000 is assessed today for a repeat violation. Facility was cited for the same deficiency on 2/27/25, 4/29/25, 5/6/25, 7/1/25 and 8/26/25

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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 09/16/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2025


LIC809 (FAS) - (06/04)
Page: 3 of 3