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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 09/15/2020
Date Signed: 09/15/2020 04:02:07 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: 51DATE:
09/15/2020
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:David WallTIME COMPLETED:
04:35 PM
NARRATIVE
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On September 15, 2020 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management inspection to deliver an amended report along with case management deficiencies related to Covid-19. LPA met with Administrator David Wall and explained the purpose of the investigation.

On September 8, 2020, LPA Hopkins and Licensing Program Manager (LPM) Montes conducted a complaint inspection. During this inspection LPA Hopkins and LPM Montes checked logs pertaining to staff temperatures. LPA Hopkins and LPM Montes received copies of temperature logs dated August 10, 2020 and noticed that 6 different staff recorded the time of day instead of their temperature. The Administrator was out of the facility at the time, so the acting administrator did not notice these mistakes. The acting administrator acknowledged that one of the employees from SFDPH stated that the thermometer had a low battery. The acting administrator then changed batteries and the thermometer still read low battery.

Also during this inspection LPM Montes toured the facility with the acting administrator and noticed that there was no evacuation chair in case of emergencies. During this inspection LPA Hopkins and LPM Montes noticed that the facility did not have a proper plan in place as required under PIN 20-23, and was not specific enough for each section. For example the facility listed CDSS employees as additional staffing sources.

Deficiencies cited under California Code of Regulations, Title 22 and California Health and Safety Code– refer to LIC809-D. Appeal rights given.

Report was discussed with Administrator David Wall. A copy of the report was given to David Wall for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2020
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 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/16/2020
Section Cited

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87405 Administrator Qualifications and Duties: (d)The administrator shall have the qualifications specified...(3)Ability to maintain or supervise the maintenance of financial and other records. This requirement is not met as evidenced by:
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Based on observation and record review, the administrator did not ensure the staff temperature log was recorded accurately, which poses an immediate health and safety risk to persons in care.
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Request Denied
Type A
09/16/2020
Section Cited

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87465 Incidental Medical and Dental Care:(a) A plan for incidental medical and dental care shall be developed by each facility...(9)If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained...(F) Thermometer. This requirement is not met as evidenced by:
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Based on observation and interviews, the administrator did not ensure that the thermometer was in working order at all times, which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/15/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
09/16/2020
Section Cited

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1569.695 Emergency Plans: (f) A facility shall have both of the following in place:(1) An evacuation chair at each stairwell, on or before July 1, 2019. This requirement is not met as evidenced by:
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Based on observation, the administrator did not ensure the facility had an evacuation chair on both stairwells, which poses an immediate health and safety risk to persons in care.
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Request Denied
Type A
09/16/2020
Section Cited

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87405 Administrator Qualifications and Duties:(a) All facilities shall have a qualified and currently certified administrator...The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility... This requirement is not met as evidenced by:
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Based on complaint investigations which resulted in serious violations, administration did not perform his duties to permit adequate attention to the management and administration of the facility, which poses an immediate health and safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2020
LIC809 (FAS) - (06/04)
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