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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 12/06/2023
Date Signed: 12/06/2023 12:27:07 PM


Document Has Been Signed on 12/06/2023 12:27 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:PEPER, DAVEFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 0DATE:
12/06/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Maintenance Director, German BrionesTIME COMPLETED:
12:30 PM
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On December 6, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on a visit conducted on 11/28/2023. LPA met with Maintenance Director, German Briones and explained the purpose of the visit. LPA also spoke to Administrator, Dave Peper via phone and explained the purpose of the visit.

On 11/28/2023, LPA Charitra conducted a health and safety visit as a result of facility being closed since April 2023 due to electrical disrepair. During the visit, LPA toured the facility to ensure facility is ready, safe, and comfortable for residents to move back. LPA observed the facility's water temperature to be fluctuating throughout the facility; not within regulatory requirements. In addition, LPA observed the faucet in the beauty salon to be leaking and in disrepair.

On 12/6/2023, LPA made a follow up visit to ensure water temperature was within regulatory requirements and to ensure the leaking faucet in the beauty salon was fixed. During the visit today, LPA checked water temperature in 9 resident apartments (3 apartments per floor), 2 communal bathrooms, and the beauty salon. Water temperature measured between 105-120 degrees F. LPA observed faucet in the beauty salon to be repaired and in good working condition.

No deficiencies are cited during the visit. LPA reviewed report with Maintenance Director 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: 12/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/06/2023
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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