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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/19/2020
Date Signed: 10/19/2020 07:32:06 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:
10/19/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
05:50 PM
MET WITH:David WallTIME COMPLETED:
07:40 PM
NARRATIVE
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On 10/19/20 Licensing Program Analyst (LPA) Chris Hopkins and Licensing Program Manager (LPM) Julio Montes conducted a case management visit to follow up on non compliance conference via telephone dated 9/30/20. LPA and LPM met with Administrator David Wall and Diana Wall RN,BSN,PHN, IP.

During the Technical Assistance inspection with Health Facilities Evaluator Nurse (HFEN) Barbie Henson on Tuesday October 13, 2020, there were 4 caregivers who demonstrated donning and doffing procedures.

The HFEN noted that staff were still lagging in their training in donning and doffing their N95 masks, and all four staff struggled with different areas on the proper use of their Personal Protection Equipment (PPE). A couple of staff tested were not able to discern that the top and bottom straps were crossed, placing the bottom strap over their hair, instead of on skin at the back of their neck. Another staff forgot to untie the gown at the waist and would have contaminated his/her arm and uniform in the manner demonstrated. The facility had not 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.

It was also noted during this tele-inspection that the room where the demonstration took place did not have hand-sanitizer on hand, as had been recommended during the previous HFEN visit. Although it was explained that the room was not in the isolation area and did not have a resident at the time of the inspection, given the recent emergency the facility just experienced, it is expected that the licensee be ready to act and to receive a resident at moments notice as indicated in the implementation plan. On September 8, 2020, the licensee was asked to complete a mitigation plan to address the shortcomings found during previous inspections by the San Francisco Department of Health (SFDPH) and CDSS. Among other preparations and recommendations, the facility needed to plan for supplying and maintaining hand sanitizers in each room to be able to react appropriately at moment notice.

Report Continued on LIC809-C...
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/19/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
10/20/2020
Section Cited

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87411 Personnel Requirements: (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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On October 13, 2020, four randomly selected staff were tested in the proper use of their Personal Protection Equipment (PPE), and all four failed in the proper donning and doffing of N-95 mask; another staff forgot to untie the gown at the waist and would have contaminated his/her arm and uniform in the manner demonstrated which poses a health and safety threat to residents in care.
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This is a repeat violation (cited on 9/14/2020). The facility has been in violation of this section and subsection within the last 12 months. Therefore, the facility is assess September 14, 2020 civil penalties
Request Denied
Type A
10/20/2020
Section Cited

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87212 Emergency Disaster Plan:(a) Each facility shall have a disaster and mass casualty plan of action. This requirement was not met as evidenced by:
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Based on observation, on October 13, 2020, during a HFEN’s tele-visit, the room did not have hand-sanitizer which poses a health and safety threat to residents 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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 10/19/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/19/2020
LIC809 (FAS) - (06/04)
Page: 3 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
VISIT DATE: 10/19/2020
NARRATIVE
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Facility representatives were informed of a meeting scheduled for October 20, 2020 to discuss the facility progress. The meeting will be attended by Administrator David Wall, Diana Wall, RN,BSN,PHN,IP. Licensee, Infection Preventionist Tangi Paama, HFEN, and CCLD representatives. This meeting is to discuss the mitigation plan and receive guidance in the right direction.


Deficiencies were observed and cited. Plan of corrections, deficiencies, and exit interview were conducted with Administrator David Wall.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2020
LIC809 (FAS) - (06/04)
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