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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 11/28/2023
Date Signed: 11/28/2023 01:22:21 PM


Document Has Been Signed on 11/28/2023 01:22 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:JOAN JOHNSONFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 0DATE:
11/28/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Joan Johnson TIME COMPLETED:
01:35 PM
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On November 28, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management health and safety visit at the facility as a result of facility being closed since April 2023 due to electrical disrepair. LPA met with Administrator, Joan Johnson, Regional Vice President of Operation with Integral Senior Living, Debi Witt, Vice President of Operation with Cogir Management, Dave Peper and Executive Vice President of with American Health Care, Ray Oborn.

LPA toured the facility inside and outside including all three of the facility floors, resident rooms, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No residents were present at the facility due to facility closure.

While touring the facility it was observed that the room temperature was at 71F. Hot water throughout the facility measured between 121-125 degrees F. Carbon monoxide monitor is working properly. All fire extinguishers have been checked and current as of October 2023. Resident apartments and bathrooms were observed to be in good repair, bathrooms equipped with grab bars and non-skid mats. Due to the emergency relocation, most residents took their personal belongings to the facilities they've been relocated to. Beauty salon faucet was observed to be leaking and in disrepair.

7-day non-perishable was present, however 2-day perishables was not present as facility is still closed. Facility will purchase 2-day perishables the day before facility reopens and provide LPA a photo of receipt of perishables purchased. Medication room and medication cabinet were both observed to be locked. Required postings were observed to be present on the 1st floor.

Facility is overall clean, however LPA to make a follow up visit to ensure facility water temperature is within regulatory requirements and faucet in the beauty salon has been repaired.

Report is reviewed with Administrator, Joan Johnson and Regional Vice President of Operation, Debi Witt.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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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