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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:22:42 PM


Document Has Been Signed on 06/16/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:MICHAEL LIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 41DATE:
06/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Resident Care Director, Ed DewittTIME COMPLETED:
03:35 PM
NARRATIVE
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On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an case management visit regarding two incidents that were reported to CCLD. LPA met with Resident Care Director (RCD), Ed Dewitt and explained the purpose of the visit.

The Licensee reported on 5/26/22, that there was a medication mismanagement that occurred and was discovered in the Wellness Center. During the visit today, LPA interviewed the Resident Care Director (RCD) and observed the Wellness Center. The Wellness center is located on the 1st floor and is locked at all times. According to the RCD, the missing medication (1 tablet) went missing sometime between the end of the PM shift and the beginning of the NOC shift. The facility conducted an immediate investigation, however did not find the missing medication. The facility has no priors of medication mismanagement. RCD trained med-techs regarding medication count and provided LPA with a completed log of an in-service training.

On June 13, 2022, the facility reported that one resident #1 (R1) AWOL (Absent Without Official Leave) on 6/3/2022. During the visit, LPA reviewed R1's file and interviewed staff. According to the files reviewed, R1 has memory changes and has mild cognitive impairment (MCI). In addition, documents reviewed also indicated that R1 is unable to leave the facility unassisted. According to the interviewed staff, R1 was seen in the dining room around 6:30pm before AWOL. R1 was missing for about an hour and returned to the community by her responsible party.

Based on interviews, and record review during the course of the investigation, the facility did not ensure basic services were being met, due to lack of supervision, R1 AWOL.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Resident Care Director, Ed Dewitt, and a copy is provided. Appeals Rights were given.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/16/2022 03:22 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 06/16/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/17/2022
Section Cited

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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).

Violation of this regulation is not met as evidenced by:
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Based on the file reviewed and interviewed conducted, the facility did not ensure basic services were being met, due to lack of supervision R1 AWOL. In addition, R1 is unable to leave the facility unassisted, which poses an immediate health, safety and personal rights risk to residents.
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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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
LIC809 (FAS) - (06/04)
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