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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 157208951
Report Date: 11/12/2021
Date Signed: 11/15/2021 12:30:44 PM

Document Has Been Signed on 11/15/2021 12:30 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, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BUENA VISTA MANOR ARF INC.FACILITY NUMBER:
157208951
ADMINISTRATOR:BAGUIO, MIAFACILITY TYPE:
735
ADDRESS:11126 VISTA DEL VALLE DRIVETELEPHONE:
(661) 885-7838
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93311
CAPACITY: 6CENSUS: 3DATE:
11/12/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Administrator Mia BaguioTIME COMPLETED:
12:30 PM
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On 11/12/21. Licensing Program Analysts (LPAs) L. Salazar and M. Yang arrived to the facility unannounced to conduct a Case Management visit. LPAs were greeted by Staff S1. COVID precautionary measures were taken and LPAs were allowed entry. LPAs toured facility and observed the facility is a 4 bedroom / 2 bathroom house. LPAs observed 3 out of 3 residents in care at the time of visit.

On 11/07/21, LPA Salazar received an incident report (LIC624) for Resident R1. Incident stated R1 had been seen by the doctor recently. Diagnosis received from Dr. is a Restricted Health Condition. LPA reviewed hospital discharge records with Administrator. LPA interviewed R1.

R1 has their own room to isolate when needed. R1 stated they apply their own medication. Staff oversees R1 in using Universal Precautionary Measures when applying the prescribed medication. R1 has access to a separate bathroom that no other residents in care have access to. Administrator, staff and resident are following Dr's instructions to include precautionary measures, to avoid any spread of infection.

No deficiency cited on today's inspection.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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