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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 12/20/2022
Date Signed: 12/20/2022 02:18:04 PM


Document Has Been Signed on 12/20/2022 02:18 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: 34DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Resident Care Director, Ed DewittTIME COMPLETED:
02:27 PM
NARRATIVE
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On December 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that was reported on December 7, 2022. LPA met with Resident Care Director (RCD) Ed Dewitt, and explained the purpose of the visit.

The Licensee reported on November 30, 2022, narcotics were missing from the lock box. The RCD immediately conducted an investigation at the facility. According to the Hospice Nurse, on 11/30/22, the nurse signed for the destruction, however did not observe the facility med-tech destroy the medications. On 12/1/22, the RCD and the Administrator spoke to the med-tech and the med-tech admitted that he/she had the hospice nurse sign for destruction without the hospice nurse being present. In addition, the med-tech indicated he/she put the narcotics in a container in the Wellness Center, however there was no container present in the room. According to the RCD, the Administrator or the RCD are the only people who destroys narcotics with another licensed nurse and the med-tech involved did not get the RCD's authorization to destroy medications.

During the visit, LPA spoke to the RCD. According to RCD, the med-tech involved was terminated on 12/1/2022 and the police department was notified. An in-service training was conducted regarding medication destruction on 12/3/2022 and a copy of the training sheet was provided.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Resident Care Director, Ed Dewitt and a copy is provided with appeals rights.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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 12/20/2022 02:18 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: 12/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/21/2022
Section Cited

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87465 Incidental Medical and Dental Care: (i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following...

Violation of this regulation is evidenced by:
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Facility conducted an in service training on 12/3/22 regarding medication destruction and provided LPA a copy of the training log. The med-tech involved in the incident was terminated.
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Based on documents reviewed and information collected, the faciliy med-tech had a hospice nurse sign for medication destruction without the hospice nurse being present for the destruction. In addition, med-tech acknowledged that he/she did not get authorization to detroy medications.
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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: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
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