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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 02/12/2020
Date Signed: 02/18/2020 01:22:12 PM

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:BUENA VISTA MANOR HOUSEFACILITY NUMBER:
380540203
ADMINISTRATOR:WALL, DAVIDFACILITY TYPE:
740
ADDRESS:399 BUENA VISTA EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:87CENSUS: 77DATE:
02/12/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:David Wall, AdministratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) made an unannounced complaint follow up visit. LPA met with David Wall, Administrator and stated purpose of visit. Shortly thereafter, LPA Raygoza conducted two staff interviews. LPA then proceeded to interview two resident's at facility. Upon exit, the following was reiterated regarding the case management: today's visit was in conjunction to the original complaint of 9/27/19.

This report was reviewed and discussed with David Wall, Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2020
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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