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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 01/04/2024
Date Signed: 01/04/2024 02:12:43 PM


Document Has Been Signed on 01/04/2024 02:12 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: 5DATE:
01/04/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Interim Administrator, Kaitlyn ClareyTIME COMPLETED:
02:22 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 January 4, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced health and safety check. LPA met with Interim Administrator, Kaitlyn Clarey and explained the purpose of the visit.

During the visit, LPA observed two residents in the dining room eating lunch, one resident unpacking their belongings in his/her room. LPA observed 7-day non-perishable and 2-day perishable.

According to Kaitlyn, there is one resident who requires assistance with medication. Medications were observed locked and inaccessible to residents. Residents interviewed indicated they were content to be back. A total of 5 residents have returned back to the facility, a few more residents are to return this weekend, and will continue till next week.

No citations are issued during the visit. Report is reviewed with Kaitlyn 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: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/04/2024
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