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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 04/20/2022
Date Signed: 04/20/2022 01:15:55 PM


Document Has Been Signed on 04/20/2022 01:15 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:VISTA TERRACE OF BELMONTFACILITY NUMBER:
415601080
ADMINISTRATOR:MICHAEL LIFACILITY TYPE:
740
ADDRESS:900 SIXTH AVENUETELEPHONE:
(650) 591-2008
CITY:BELMONTSTATE: CAZIP CODE:
94002
CAPACITY:68CENSUS: 48DATE:
04/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Interim Executive Director, Ryan Mussato TIME COMPLETED:
11:15 AM
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On April 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 4/11/2022. LPA met with Interim Executive Director, Ryan Mussato and explained the purpose of the visit.

During the visit, LPA reviewed resident's (R1's) file and received documents in relation to the incident. LPA Charitra interviewed the Interim Administrator. An updated care plan was submitted to LPA by email. During this time, R1 was at the hospital for a routine check up.

This incident requires further investigation.

This report is discussed and reviewed with Interim Executive Director, Ryan Mussato. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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