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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/20/2020
Date Signed: 11/20/2020 04:08:36 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:
11/20/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:Diana WallTIME COMPLETED:
04:00 PM
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On November 20, 2020, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst Albert Johnson conducted an unannounced case management visit via Microsoft Team. The team met with Administrator and Diana Wall, RN,BSN,PHN,IP, Infection Preventionist Tangi Paama

During the tele-visit, the team toured the outside sitting area, dining prep area, three residents rooms on two levels and staff break room. The team observed the COVID WING on the third floor with the additions of the staff quarters for breaks, lunch and rest. The department has the revised mitigation plan and training plan which has been vetted and approved.

As of right now the facility is still only allowing essential workers into the facility. They have communal dining and group activities projected to start some time next week. Weekly staffing schedules have been provided. The Department continues to receive updates from the facility and if there are changes the facility is to send a revised or new schedule.

No deficiencies were observed during today’s call. Exit interview was conducted with Diana Wall where LPA reviewed report with Diana 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: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
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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