380540203-10-26-2020-14-AS-AJON-BURUCM-20201026152810

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/21/2020
Date Signed: 10/26/2020 03:28:18 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 HOUSE		FACILITY NUMBER:	380540203
ADMINISTRATOR:	WALL, DAVID		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS: 47	DATE:	10/21/2020
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	03:03 PM
MET WITH:	David Wall		TIME COMPLETED:	06:15 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 10/21/20 Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Program Clinical consult support, Paul Portem, Health Facilities Evaluator Nurse (HFEN) Barbie Henson, Regional Manager (RM) Krystall Moore and Assistant Program Administrator (APA) Stacy Barlow conducted an unannounced case management visit. LPA, LPM, RM and APA met with Administrator David Wall. During the tele-visit, two caregivers demonstrated donning and doffing procedures. The HFEN confirmed that staff performed well with the donning and doffing of their Personal Protection Equipment (PPE). The facility has posted the donning and doffing sequence signage recommended during the previous HFEN visit/testing. The CDC sequence indicates the use of hand sanitizer at each step of removing PPE if anything gets contaminated during the process. Also noted during this tele-inspection the room where the demonstration took place did have hand sanitizer on hand, as had been recommended during the previous HFEN visit. The facility is testing at twenty five percent now. Nurse informed Administrator that all staff working in the facility are ok to wear surgical mask, because there are no positive residents in the facility now. As of right now they are 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.

SUPERVISOR'S NAME: Anthony Perez	TELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

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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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: 10/21/2020

NARRATIVE

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Administrator stated that he does have a sufficient supply of N95's. The facility received N95's mask, gowns and gloves from the county today. Nurse stated she is OK with reusing the N95 for training only. Signs are located on the outside of the resident doors. There are trash can inside and outside of the rooms that staff can dispose of used PPE. Nurse reviewed cleaning products and cleaning techniques.

The Department will continue tele-visits three times per week with one of the days unannounced including a nurse. The mitigation plan will be submitted to the department by 10/22/2020 and to the local public health department prior to approval.

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 Perez	TELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert Johnson	TELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2020

LIC809 (FAS) - (06/04)

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