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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 03/19/2024
Date Signed: 03/19/2024 01:10:13 PM


Document Has Been Signed on 03/19/2024 01:10 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: 13DATE:
03/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Kaitlyn Clarey TIME COMPLETED:
01:20 PM
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On March 19, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual inspection. LPA met with Administrator, Kaitlyn Clarey and explained the purpose of the visit.

LPA toured the facility inside and outside including but not limited to; resident rooms, communal bathroom, common areas & kitchen. The indoor and outdoor passageways were free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a three story facility. LPA toured main dining room and kitchen on the first floor. Residents were observed eating lunch. LPA observed 2 days perishables and 7 days non-perishables. LPA observed medication room to be locked and inaccessible to residents. Communal bathrooms on the first floor were clean and in good repair. Communal area on the third floor was observed clean and free from tripping hazards.

Chemicals, medications, and sharps were locked and inaccessible to residents. Hot water temperature throughout the facility was between 113-115 degrees. Carbon monoxide detectors are working properly. All fire extinguishers have been checked and current as of October 2023. Emergency drills are logged and done monthly. Extra linen and first aid kit was observed present. Temperature throughout the facility is comfortable and lighting is sufficient for comfort.

LPA reviewed 5 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

No citations are issued during the visit. Report is reviewed with the administrator 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: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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