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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601080
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:21:53 PM

Unsubstantiated


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
12/10/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241210153327
FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:KAITLYN CLAREYFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 28DATE:
12/11/2024
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator, Kaitlyn ClareyTIME COMPLETED:
01:45 PM
ALLEGATION(S):
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Staff do not ensure that resident's toilet is in good repair
Staff do not ensure that the facility temperature is comfortable
INVESTIGATION FINDINGS:
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On December 11, 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 do not ensure that resident's toilet is in good repair, according to the reporting party, the toilet in Resident 1’s (R1’s) room has been broken and repaired approximately three times recently. In addition, reporting party stated the toilet lever isn't working in the R1’s room.

During the investigation, LPA toured R1’s room and observed the toilet. Toilet was observed to be in good working condition and the toilet lever was observed to be in good repair.

Regarding the allegation staff do not ensure that the facility temperature is comfortable, according to the reporting party, the dining room is cold and the staff don’t turn the heat on in the dining room. (Cont. to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20241210153327
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: 12/11/2024
NARRATIVE
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During the investigation, LPA interviewed residents and toured the dining. The dining room temperature was observed to be at 74 degrees F. LPA interviewed 5 residents, according to 4/5 residents interviewed, all 4 residents indicated that the dining room was at a comfortable temperature and they felt warm.

Based on observations and interviews conducted, the department has determined that although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with Administrator and a copy is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2