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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/10/2020
Date Signed: 10/10/2020 02:01:12 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: 49DATE:
10/10/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David Wall and Diana WallTIME COMPLETED:
02:30 PM
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On 10/10/20 Licensing Program Analyst (LPA) Chris Hopkins and Licensing Program Manager (LPM) Julio Montes conducted a case management visit to follow up on non compliance conference, along with a Technical Assistance facetime tour with Health Facilities Evaluator Nurse (HFEN) Barbie Henson. LPA and LPM met with Administrator David Wall and Diana Wall RN/PHN.

LPA and LPM conducted a technical assistance visit with the HFEN, and during this visit HFEN observed screening process for visitors and staff before the start of their shift. HFEN mentioned that the screening process was very detailed. HFEN observed the bathroom in the lobby area making sure there were hand washing signs along with soap and paper towel dispensers. HFEN then observed floor 3, which included going inside of a vacant room and suggesting once a Covid positive resident comes in that room, that signs be posted in the room for reminders to them and staff. HFEN observed a staff donning and doffing PPE, provided suggestions and made a couple of corrections, but indicated that the procedure was acceptable.

LPA and LPM conducted a separate visit to address the non compliance. During the visit the licensee informed LPA and LPM, Diana Wall had obtained a infection preventionist certificate, and provided a copy; CCL representatives were also informed that a Infection Preventionist had been hired, with a starting date of Monday October 12, 2020. The facility has also hired 1 new administrator with an offer pending for another. Licensee resubmitted a more detailed mitigation plan clarifying procedures that should be followed by staff to Assistant Program Administrator (APA) Pam Gill October 9, 2020. During the visit LPA and LPM received a copy of the updated LIC500.


Report continued on LIC809-C...


SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 10/10/2020
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During the visit, LPA and LPM observed the following:
-Evacuation chairs in stairwell
-Staff wearing proper PPE
-Staff in laundry room wearing PPF
-Elevator working properly
-Resident rooms
-Doorknobs

The administrator stated the census is 49 (administrator provided LPA and LPM with resident roster), the increase of census was due to residents coming back from rehab. There are 2 more residents planning to come back from a Skilled Nursing Facility. There are currently no residents on hospice. There are no cases of positive Covid in the facility within staff or residents. There are 30 staff on duty today 10/10/20. There was a mass testing done yesterday 10/9/20, 11 staff were tested, results pending. Administrator stated that there is a plan for testing every 7 days.

No deficiencies cited today

This report was reviewed with Administrator David Wall and a copy of this report was provided.






SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2