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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601022
Report Date: 04/26/2023
Date Signed: 04/26/2023 01:30:09 PM


Document Has Been Signed on 04/26/2023 01:30 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: 75DATE:
04/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator, Corey MillerTIME COMPLETED:
01:40 PM
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On April 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 4/11/2023. LPA met with Administrator, Corey Miller and explained the purpose of the visit.

The Licensee reported on April 11, 2023, Resident 1 (R1) alleged that a staff member (S1) inappropriately touched him/her. At this time, the administrator suspended S1 from working at and conducted an internal investigation.

During the visit today, LPA reviewed R1's file, S1's file and interviewed the administrator. Based on documents reviewed, R1 is a newly admitted resident with a diagnosis of Alzheimer's disease. In addition, based on R1's needs and services, R1 is incontinent and requires assistance to be changed about 6-7x a day.

According to the administrator, based on the internal investigation, it was found that there was no evidence of abuse and S1 has no prior history of alleged abuse. In addition, the staff immediately conducted a head-to-toe assessment and did not observe R1 in distress and did not observe R1 to have any injuries/bruising. Furthermore, the administrator spoke to R1's responsible party and did not find any evidence of abuse.

Based on the information collected, there was no deficiencies found and this incident does not require any additional investigation.

This report is discussed and reviewed with Administrator, Corey Miller 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: 04/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2023
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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