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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/02/2020
Date Signed: 11/02/2020 06:09:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
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: DATE:
11/02/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator David WallTIME COMPLETED:
03:31 PM
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On 11/02/2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore and Health Facilities Evaluator Nurse (HFEN) Barbie Henson conducted an announced case management visit. The team met with Administrator David Wall and Infection Preventionist Tangi Paama.

During the tele-visit, the team toured the Activity area and the designated COVID positive area. Also observed during the tour were two caregivers who demonstrated Personal Protection Equipment (PPE) donning and doffing procedures. While in the COVID designated area, the team observed the PPE supply closet, STOP signs on the interior of the resident room doors, PPE stations throughout, wall mounted towel dispensers near the PPE areas, foot pedal trash cans, laundry containers and a COVID designated medcart. Time was spent and recommendations were made for a doffing area to be included at the end of the hall. Mention of a plastic barrier was discussed and further follow up will be provided by the HFEN during the next TA.

The Department has requested the revised mitigation plan, training plan and training logs to be submitted by Tuesday, November 3rd, 2020 by close of business. The RO has also requested the prospective Administrator applicant package be submitted to the RO by end of day on Wednesday, November 4, 2020.

No deficiencies were observed during today’s call. Exit interview was conducted with David Wall where LPM 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 LPM to be filed.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020
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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