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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 06/16/2022
Date Signed: 06/16/2022 03:22:04 PM


Document Has Been Signed on 06/16/2022 03:22 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
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: 41DATE:
06/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Resident Care Director, Ed DewittTIME COMPLETED:
03:35 PM
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On June 16, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. LPA met with Resident Care Director (RCD), Ed Dewitt and explained the purpose of the visit. LPA was screened at entry point and RCD was able to provide screening log documentation for staff, visitors, and residents.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a 3 story building with rooms on each floor. LPA observed the laundry room on each floor to be fully functioning and in good repair. LPA observed 4 residents maintaining social distancing in the activities room on the 2nd floor. 30-day PPE supply was observed on the second floor storage room. LPA toured the 1st floor and observed the dining room to have tables 6ft apart to maintain social distancing. Communal bathrooms were equipped with liquid soap and paper towels; LPA advised to cover trash cans with lids in all bathrooms. The Wellness center room on the 1st floor was observed to be locked with resident files and medication. LPA observed the dining hall to have tables 6ft apart to maintain social distancing.

Infection control practices are reviewed: entry procedures, staff training and policies, resident/ visitors/ and staff daily monitoring records, and 30-day PPE supply. LPA advised to put social distancing and masking sign on the elevator door.

Toxins and sharps are stored appropriately and inaccessible to residents, and a comfortable temperature is maintained. Lighting is sufficient for comfort. First aid kit was observed to be completed.

LPA requests the following documents to be submitted to CCLD by June 23, 2022:
  • LIC309 Administrative Organization
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • Administrator Certificate
  • LIC610E Emergency Disaster Plan

Report is reviewed with Resident Care Director, ED Dewitt and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 06/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/16/2022
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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