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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 05/01/2023
Date Signed: 05/03/2023 09:35:05 AM


Document Has Been Signed on 05/03/2023 09:35 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
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:
05/01/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Management Company, Integral Senior LivingTIME COMPLETED:
02:00 PM
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On May 1, 2023, San Bruno Regional Office conducted a Microsoft Teams meeting with Integral Senior Living (ISL) Management along with the Santa Rosa and Oakland Regional Office. During this meeting, the offices discussed the emergency evacuation that occurred on 4/28/2023 due to a power outage that was reported on 4/25/2023. Residents were relocated back home with their families or to the sister facilities; Windsong of Sonoma located in Petaluma or The Point at Rockridge located in Oakland.

Present in this meeting was Assistant Program Administrator, Pam Gill, Regional Manager, Vivien Helbling, Licensing Program Manager, Cara Smith, Licensing Program Analyst, Komal Charitra from the San Bruno Regional Office, Regional Manager, Issac Taggart, Licensing Program Manager, Yvonne Flores from the Oakland Regional Office, Licensing Program Manager, Bethany Moellers from the Santa Rosa Regional Office, Long Term Care Ombudsman, Tom Barrett and Nikki Manske (San Mateo County) and Kiev Harris (Alameda County). In addition, present in this meeting was Director of Operations, Cossandra Blair, Senior Vice President of Operations, Mike Zeug, Interim Administrator, Joan Johnson and additional representatives from ISL.

During this meeting, the following was discussed; reassessment of residents after relocation (transfer trauma/injuries), communication between facilities, families and residents, maintenance and repair time-frame, medical transportation, admission agreement addendum, staffing, updated plan of operation for all three facilities in regards to the emergency relocation of residents.

--Licensee/Administrator to submit an updated LIC500 (staff schedule) for Windsong of Sonoma and The Point at Rockridge
-- Licensee/Administrator to provide LPA with a copy of the electricians report from 4/29/23.
--Licensee/Administrator to provide LPA with an updated plan of operation for all three facilities
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 05/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/01/2023
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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