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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380540203
Report Date: 09/14/2020
Date Signed: 09/14/2020 07:24:08 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/07/2020 and conducted by Evaluator Christopher Hopkins-Clarke
COMPLAINT CONTROL NUMBER: 14-AS-20200907115538
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:
09/14/2020
UNANNOUNCEDTIME BEGAN:
03:33 PM
MET WITH:David WallTIME COMPLETED:
07:30 PM
ALLEGATION(S):
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-Elevator is not working properly
-Current facility floor plan and emergency disaster plan are not posted
-Staff are not following proper use of PPEs
-Soiled diaper are not being properly disposed
-Facility not reporting positive COVID-19 cases and deaths in the facility.
INVESTIGATION FINDINGS:
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On 9/14/20 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced complaint investigation regarding the above allegations. LPA met with Administrator David Wall and explained the purpose of the investigation.

Regarding the allegation of elevator not working properly, during the visit on September 8, 2020 Licensing Program Manager Montes toured the facility. The elevator was found to be in working order, however there was a loud squeaky metal noise when going up and down. Facility staff acknowledged that the elevator needs maintenance but due to the pandemic, elevator maintenance is not considered essential. Facility administrator has failed to be proactive seeking allowances to service elevator. Based on the observations, there is preponderance of evidence to indicate that the elevator needs maintenance and is not working properly.

Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
Control Number 14-AS-20200907115538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2020
NARRATIVE
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Regarding the allegation of Current facility floor plan and emergency disaster plan are not posted, during the initial visit on September 3, 2020 it was noted that the facility was missing the newer LIC 610E, developed specifically to attend and address emergencies. Based on this information, there is preponderance of evidence to show LIC 610E was not up to date.

Regarding the allegation of staff not following proper use of PPE's, during SFDPH inspection, staff were observed failing to use masks/ gloves appropriately, and no other staff challenging or supervising them, showing them the correct use of PPE's. During the visit on September 8, 2020 LPA and LPM observed the maintenance staff not wearing gloves. It was indicated that he is following guidelines from the CDC. The statement could not be corroborated with documentation from the CDC. Based on this information, there is preponderance of evidence to show that the staff was not following proper use of PPEs.

Regarding the allegation of soiled diapers not being properly disposed, During SFDPH visit to this facility on August 4, 2020, there were two residents in isolation rooms on the third floor. One of the residents was observed to be incontinent, wearing a diaper, and there was a soiled diaper on the floor. The resident wanted water and also wanted to go to the restroom, apparently unaware to be wearing a diaper. Staff who were interviewed stated that indeed, during SFDPH there were two residents in isolation in the third floor who were being monitored through the balcony window. Staff denied that soiled diapers are disposed inappropriately, indicating that diapers are disposed by placing them in bins available in each room and along the corridor. These bins were observed during the walk-through. However, staff acknowledged that supervision of those residents in the isolated areas was rather restricted. When questioned by SFDPH about monitoring the residents at night, staff was unable to provide for a plan. Therefore, it is more likely than not that facility failed to follow or to have developed a plan to address incontinency as required.

Report Continued on Additional LIC 9099C
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20200907115538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2020
NARRATIVE
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Regarding the allegation of not reporting positive Covid-19 cases and deaths in the facility, This allegation refers to the facility providing different and inconsistent information regarding the COVID-19 outbreak, resulting in inaccurate reporting and delayed responses. The facility current administrator was personally affected by the outbreak, requiring him to be out of the facility. Rather than hiring or finding a qualified replacement who could manage the emergency, the administrator attempted to run the facility remotely, resulting in inaccurate reporting, and delaying swift resolution to concerns being found at the facility. As a result of this lack of oversight, there is a discrepancy in the count of residents affected by the pandemic between State (Licensing) and County (SFDPH). Staff has indicated that the discrepancy is due to residents passing away from the facility, and/or passing from other causes other than COVID-19. The inconsistency is due to the facility providing conflicting information to different agencies. Based on this information, there is preponderance of evidence that the facility failed to report changes due to the administrator not spending sufficient amount of time at the facility or failing provide oversight.

Based on LPAs observations, interviews, and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies cited under California Code of Regulations, Title 22

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

DATE: 09/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 14-AS-20200907115538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/15/2020
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, and sanitary and in good repair at all times. This requirement is not met as evidenced by:
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Administrator has stated that the elevator has been serviced as of 9/10/20.

Administrator will send receipt of service to CCLD by due date 9/15/20
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Based on observation, the administrator did not ensure the elevator was serviced, which poses an immediate health, safety, and personal rights risk to persons in care.
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Deficiency Dismissed
Type A
09/15/2020
Section Cited
CCR
87212(a)
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87212 Emergency Disaster Plan: (a) Each facility shall have a disaster and mass casulty plan of action. The plan shall be in writing...This requirement was not met as evidenced by:
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Administrator has submitted updated LIC 610E on 9/14/20.
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Based on observation and record review the administrator did not ensure the facility emergency disaster plan was efficient and up to date, which poses an immediate health, safety, and personal rights 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: 09/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 14-AS-20200907115538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/15/2020
Section Cited
CCR
87411(a)
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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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Administrator has stated that his facility has received training on how to use PPE from Public Health Nurse on 9/11/20, 9/12/20, and 9/13/20.

Administrator has agreed to send training logs by due date 9/15/20
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Based on observation, administrator did not ensure the facility staff were wearing PPE correctly or wearing at all, which poses an immediate health, safety, and personal rights risk to persons in care
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Request Denied
Type A
09/15/2020
Section Cited
CCR
87625(b)(2)
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87625 Managed Incontinence:(b) In addition to section 87611...(2)Ensuring that incontinent residents are checked during those periods of time when they are known to be incontinent, including during the night. This requirement was not met as evidenced by:
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Administrator has agreed to have staff check incontinent residents throughout the day and night.

Administrator will send staff schedule to CCLD by due date 9/15/20
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Based on observation, the administrator did not ensure residents were being changed or disposing diapers properly, which poses an immediate health, safety, and personal rights 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: 09/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20200907115538
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/15/2020
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements: (a)Each licensee shall furnish to the licensing agency such reports as the Department may require...(2)Occurrences, such as epidemic outbreaks...major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidence by:
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Administrator has agreed to read Title 22 and be consistent with reporting and reporting immediately.

LPA received latest report on Covid cases from Administrator on 9/14/20
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Based on observation and records review the administrator did not ensure all Covid-19 related cases were reported in a timely and accurate manner, 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: 09/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020
LIC9099 (FAS) - (06/04)
Page: 6 of 6