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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 04/04/2022
Date Signed: 04/04/2022 11:58:19 AM


Document Has Been Signed on 04/04/2022 11:58 AM - It Cannot Be Edited

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:MILLER, COREYFACILITY TYPE:
740
ADDRESS:1010 ALAMEDA DE LAS PULGASTELEPHONE:
(650) 508-0400
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:117CENSUS: DATE:
04/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Corey Miller TIME COMPLETED:
12:15 PM
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On April 4, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an Incident Report that was received on March 31, 2022. LPA was greeted by the Executive Director, Corey Miller. LPA Charitra explained the purpose of the visit.

On March 31, 2022, According to the Incident Report, Resident 1 (R1) was observed to push Resident 2 (R2) causing R2 to fall and sustain a hip fracture. This is the second altercation R1 has had within the same month. On March 13, 2022, R1 was witnessed pulling another resident's (R3) hair; no injuries were noted. Since the first incident, the facility has increased supervision for R1.

LPA reviewed both resident's files for this incident which indicated both R1 and R2 have a diagnosis of Dementia with Alzheimer's. According to the Administrator and the Memory Care Coordinator, Kristin Marcos, facility contacted R1's primary physician for a reassessment and is awaiting new medication orders. In addition, facility is contacting R1's responsible party in regards to moving R1 from a shared room to a private room.

Facility informed Ombudsman, Licensing, Physicians, and the resident's Responsible Party regarding this Incident.

No deficiencies were issued.

Report was reviewed with Executive Director, Corey Miller.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
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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