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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 11/21/2022
Date Signed: 11/21/2022 12:21:22 PM


Document Has Been Signed on 11/21/2022 12:21 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: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: 74DATE:
11/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Corey MillerTIME COMPLETED:
12:30 PM
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On November 21, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance and was screened at entry point. LPA met with Executive Director, Corey Miller and explained the purpose of the visit.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a three story facility; with Assisted Living (AL) residents on the first, second, and half of the third floor and Memory Care on the other half of the third floor. LPA toured the facility with the Executive Director and observed the communal bathrooms on each floor to equipped with paper towels, hand washing signs, liquid soap, grab bars, and a trash can with a fitted lid. The bathrooms were clean and odor-free.

LPA observed four medication carts at the facility all to be locked and inaccessible to residents in care. There was a laundry room located on each floor observed to be locked. According to the Executive Director, the laundry rooms stays locked at all times. Chemicals and toxins are locked and stored appropriately and inaccessible to residents. The Wellness office was observed to be on the second floor. 30-day PPE supply is located on the second floor. Elevators were observed to have masking and social distancing signs posted.

LPA observed the dining room on the first floor to have tables 6ft apart from each-other. LPA toured the kitchen located on the first floor and observed 2 day perishable and 7 day non-perishable. LPA toured the Activities Room on the second floor and observed 3 residents playing cards together while maintaining social distancing. During the visit, LPA observed staff with face coverings.

LPA observed the dining room and the living room in AL and Memory Care be clear and free from any tripping hazards. A comfortable temperature of 73 degrees F is maintained and lighting is sufficient for comfort. COVID-19 signage was posted throughout the facility. First aid kit was observed to be completed. Infection control practices are observed: COVID signage posted throughout the facility, entry procedures, daily monitoring log for staff, residents and visitors, 30-day PPE supply, face coverings for staff, containment strategies, staff training and policies.

No citations issued during the visit. Report is reviewed with Executive Director and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/21/2022
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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