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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601080
Report Date: 06/28/2022
Date Signed: 06/28/2022 10:00:27 AM


Document Has Been Signed on 06/28/2022 10:00 AM - 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: DATE:
06/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Interim Executive Director, Ryan Mussato TIME COMPLETED:
10:05 AM
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On June 28, 2022, Licensing Program Analyst (LPA) Komal Charitra, conducted an unannounced case management visit to follow-up on a visit that LPA conducted on 4/20/2022 concerning an incident that occurred on 4/11/2022.

The Department referred this incident to the Investigation Branch. An investigation regarding Resident #1 (R1) was conducted by Investigation Branch and based on the information collected, there was no deficiencies found and this incident does not require any additional investigation. This investigation is closed.

Report is reviewed with Interim Executive Director, Ryan Mussato 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: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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