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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 10/08/2020
Date Signed: 10/30/2020 12:23:01 PM

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:SUNRISE ASSISTED LIVING OF BELMONTFACILITY NUMBER:
415601022
ADMINISTRATOR:PADILLA, VERONICAFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: 61DATE:
10/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Veronica Padilla TIME COMPLETED:
12:15 PM
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On October 8, 2020, Licensing Program Analyst (LPA) Buksh, conducted a visual inspection with Executive Director, Veronica Padilla. The inspection was conducted regarding the incident that occurred on September 23, 2020 and was reported to CCLD by Executive Director.

It was reported that resident (R1) had eloped from the facility on September 23, 2020 at around 7:35PM from the front entrance. The alarm signal went off, warning staff when R1 left the building. R1 was found by facility staff across the street. R1 was brought back to the facility and assessed for injuries. According to the Executive Director, no injuries were observed. Facility re- assessed R1's care plan and R1 was moved to memory care from Assisted living. During the visual inspection, LPA toured the facility to check the alert devices that monitors exits and discussed solutions with Executive Director. Executive Director has updated their elopement plan and would share with CCLD. Facility is in process to re -assess and re-develop care plan for all residents in assisted living regularly for cognitive level check and wandering behaviors to develop better care plan for the residents and also provide additional in - service training to caregivers on elopement.

The inspection report was emailed to Executive Director for review and signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Shabana BukshTELEPHONE: (650) 266-8810
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2020
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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