<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/26/2020
Date Signed: 10/26/2020 03:52:15 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: 48DATE:
10/26/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:33 PM
MET WITH:David WallTIME COMPLETED:
04:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/26/2020, Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Health Facilities Evaluator Nurse (HFEN) Barbie Henson, Regional Manager (RM) Krystall Moore and Representative Benson Nadell (Ombudsman's office) conducted an announced case management visit. The team met with Administrators Mary Webster and David Wall, Infection Preventionist Tangi Paama and Diana Wall, RN,BSN,PHN,IP.

Surveillance testing was completed for 10 staff, no results at this time. The facility will be testing 10 residents today. The facility also provided a schedule to the department and there are no changes from what was received over the weekend. The facility put into place mobile chart with PPE equipment, N-95 mask, face shields, hand sanitizer, wipes, gowns and gloves. The HFEN suggested that the cart have paper towel dispensers or to avoid contamination.

The facility will put into place today "stop signs" or something on the inside of the positive COVID rooms as a reminder to residents not to come out and to request assistance. The facility will send pictures this evening confirming signs are up. There are four caregivers working today (10/26/2020) and the HFEN has requested to observe one staff person donning and doffing Personal Protection Equipment (PPE). The HFEN confirmed that the staff performed well with the donning and doffing of PPE.

The team continued the tour to the medication room and observed locked cabinets where medication are stored. There is a separate locked area for the controlled medication in the medication room. The facility will have a medication cart on the 3rd floor and provide pictures once purchased.

Continued
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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: 10/26/2020
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As of right now, the facility is only allowing essential workers into the facility. They were advised to not have communal dining or group activities until the local health department reviews the plan. The plan has been received and will be reviewed with recommendations if needed.

The Department will continue tele-visits three times per week with one of the days unannounced including a nurse via Microsoft Teams.

No deficiencies were observed during today’s call. Exit interview was conducted with David Wall where LPA reviewed report with David via telephone. An electronic copy of the report was emailed to the facility to obtain a signature from the Administrator and emailed back to LPA to be filed.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2