<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 04/28/2023
Date Signed: 04/28/2023 02:50:34 PM


Document Has Been Signed on 04/28/2023 02:50 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: 36DATE:
04/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Interim Administrator, Joan Johnson TIME COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On April 28, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced Health and Safety case management visit as a result of an emergency evacuation due to a power outage that was reported on 4/25/23. LPA met with Interim Administrator, Joan Johnson and explained the purpose of the visit.

On 4/24/23, the facility had a power outage. During the time, the facility did have two back up generators, sufficient food supply, 30-day supply of resident medications, and hot water. Residents were provided with lanterns for their rooms at night and extra blankets if they were cold. On 4/27/23, the facility notified CCL that all residents will be relocated due to the main breaker switch being in disrepair. According to the Interim Administrator, it may take weeks to months to repair it as the facility needs a city permit and PG&E's approval.

All residents will be relocated to the facility's sister facilities, The Point at Rockridge located in Oakland, and Windsong of Sonoma located in Petaluma. According to the Interim-Administrator, as of now 12 residents will be relocated to the facility in Oakland, 21 will be relocated to the facility in Petaluma, and 3 will be moved back home with family.

During the visit, LPA toured the facility, observed sufficient staffing present, observed movers packing resident furniture, facility staff assisting with talking to residents and helping other facility staff and residents pack up their belongings. LPA observed another back-up generator being installed. For residents going back home with family, their responsible parties will sign off on the medications and take it home and for the residents who are going to sister facilities, the staff will take the medications and all resident files with them. The facility's goal is to move out all residents by this evening. Staff will be accompanying residents to their new facility.

The facility has scheduled an electric testing company to come to the facility tomorrow morning to evaluate current systems. LPA will continue monitoring the facility. Facility to send LPA a copy of LIC9020- Resident Roster as soon as possible.

No citations issued during this visit. LPA reviewed report with Joan Johnson 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: 04/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1