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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 10/10/2022
Date Signed: 10/10/2022 12:51:05 PM


Document Has Been Signed on 10/10/2022 12:51 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
SF COASTAL AC/SC, 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: DATE:
10/10/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Executive Director, Siobhan SurracoTIME COMPLETED:
12:55 PM
NARRATIVE
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On October 10, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that was reported to CCLD on October 6, 2022. LPA met with Executive Director, Siobhan Surraco and explained the purpose of the visit.

The Licensee reported on September 18, 2022, Resident #1 (R1) and Resident #2 (R2) missed a dosage of their standing orders for their medications due to Med-Tech error. According to the Licensee, the error was discovered the same day during the change of shift. In addition, it was indicated that the Med-Tech reported he/she made a mistake and was rushing.

During the visit, LPA spoke to Executive Director and Resident Care Director, Ed Dewitt and reviewed R1's and R2's files. Based on file reviewed, R1 has a diagnosis of cognitive impairment and diabetes. R2 has a diagnosis of Escherichia coli with muscle weakness. According to the Resident Care Director, the missed medications were prescriptions ordered by both resident's physicians.

Based on record reviewed and staff interviews, the facility Med-Tech missed a dosage of R1 and R2's prescribed medication which were ordered by their physician.

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 Executive Director, Siobhan Surraco, and a copy is provided. Appeals Rights were given.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
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 10/10/2022 12:51 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
SF COASTAL AC/SC, 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: 10/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2022
Section Cited

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87465 Incidental Medical and Dental Care: (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration...(2) Once ordered by the physician the medication is given according to the physician's directions.

Violation of this regulation is evidenced by:

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Based on record reviewed and staff interviews, the facility Med-Tech missed a dosage of R1 and R2's prescribed medication as ordered by their physician.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2022
LIC809 (FAS) - (06/04)
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