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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 01/12/2023
Date Signed: 01/12/2023 07:03:10 PM


Document Has Been Signed on 01/12/2023 07:03 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:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:SIOBHAN SURRACOFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 30DATE:
01/12/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
05:45 PM
MET WITH:Administrator, Siobhan SurracoTIME COMPLETED:
07:15 PM
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On January 12, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Health and Safety visit as a result of the Department receiving notice from Emergency Services of San Mateo and the Long-Term Care Ombudsman regarding the power outage at the facility due to the storm. LPA met with Resident Care Director, Ed Dewitt and Administrator, Siobhan Surraco and explained the purpose of the visit.

During the visit, LPA toured all three floors of facility. LPA observed 2 day perishable and 7 day non-perishable present. Residents were observed socializing on the third floor and dining on the first floor dining room. A comfortable temperature of 68-69 degrees F is maintained on all floors. Facility has a backup generator and is able to provide sufficient lighting in the hallways of the facility. Bedrooms were observed to have no power, however residents were given flashlights and lanterns for their rooms.

According to the Administrator, the facility has restored hot water to partial areas of the facility for residents to take shower. In addition, a larger generator will be arriving tomorrow. Proof of generator will be submitted to CCL tomorrow with a copy of plan of operation for this emergency.

Report reviewed with Administrator and a copy is provided. No citations issued during this time.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/12/2023
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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