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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/06/2020
Date Signed: 11/09/2020 03:23:12 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, 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:
11/06/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
02:00 PM
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On November 6, 2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, LPA Albert Johnson and LPA Ashley Boothe conducted an announced case management visit via Microsoft Team. The team met with Administrator David Wall, Infection Preventionist Tangi Paama and Diana Wall, RN,BSN,PHN,IP.

During the tele-visit, the following areas were observed: the designated COVID positive area, Memory Care area, various restrooms throughout the facility, kitchen and dining area, staff break areas, resident seating area and activity area. Two residents were observed in their private rooms, the residents appeared well groomed, each were out of bed, one reading a magazine while seated in his wheelchair and the other resident ambulatory tinkering about. Both residents were engaged in conversation and were pleasant. Their beds were made and the rooms appeared tidy. In the common area of the Memory Care, another ambulatory resident was observed, pleasant when greeted, groomed and attire was appropriate. While in the COVID designated area, the team observed the 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, plastic barrier, and designated break area for COVID designated staff. Observation of the break areas, included new signage of cleaning procedures and readily available disinfectant. Two resident bathrooms and six common area hand washing basins were observed with the appropriate hand washing signage as requested by the HFEN on the previous visit. The activity area had small tables stacked on top of one another, the RO requested they be repositioned as their current positioning creates an unsafe environment.

The Department and the Local Health Department
has received and approved the mitigation plan dated 11/03/2020 and approved 11/06/2020 with revisions. In addition, the Department has vetted two individuals for the Administrator position as requested. The facility will plan to hire both by Friday November 14, 2020. The RO requested PPE training logs for the week and the residents virtual visit log for the week to be submitted by end of day November 7, 2020. The RO has arranged for additional N95 masks through the Department. Per the request of the department during the previous TA visit, the facility has coordinated as requested with the LHD for additional N95 masks. The Department requested that COVID designated staff be fit tested by end of day Monday November 9, 2020 per the request of the Local Health Department .

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: 11/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2020
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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