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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 01/11/2022
Date Signed: 01/11/2022 03:43:14 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: 67DATE:
01/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director, Corey MillerTIME COMPLETED:
04:00 PM
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On January 11, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA observed COVID-19 signs posted by the front entrance. LPA was greeted by the Executive Director (ED), Corey Miller. LPA Charitra explained the purpose of the visit. Temperature was taken and COVID screening questions were asked. ED was able to provide LPA with screening log documentation for staff and visitors.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident/ visitors/ and staff daily monitoring records, and 30-day PPE supply. LPA observed the elevators and advised to post signs to indicate how many people can go in the elevator per ride. LPA observed the dining hall to have tables 6ft apart to maintain social distancing.

LPA observed bathrooms to be equipped with paper-towels, liquid soap, hand-washing signage, and a covered trash bin. LPA toured the kitchen and observed sufficient amount of perishable and non-perishable foods.

Medications carts were observed to be locked. LPA observed the well-ness room located on second floor where resident files are stored. Toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed.

LPA requests the following documents to be submitted to CCLD by January 18, 2022:
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
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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