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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/10/2020
Date Signed: 01/04/2021 09:38:30 AM

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:
11/10/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:David WallTIME COMPLETED:
02:00 PM
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On November 10, 2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, Health Facilities Evaluator Nurse (HFEN) Barbie Henson and Program Clinical Consultant Paul Portem conducted an unannounced case management visit via Microsoft Team. The team met with Administrator David Wall, and Diana Wall, RN,BSN,PHN,IP. During the tele-visit, the following areas were observed: the designated COVID positive area, various restrooms throughout the facility, activity area, med room and three Assisted Living resident bedrooms and restrooms. There were no concerns noted. Residents observed, were engaged in conversation and were pleasant. While in the COVID designated area, the team observed all previous guidance being followed. A new addition to the COVID area was the mitigation plan laminated and at each end of the hallway posted. Three resident private rooms and two common area hand washing basins were observed, all previous guidance being followed. The previous staked tables in the activity area had been removed. The facility plans to hire two new Administrators by Friday November 14, 2020. The RO has received the requested training logs and resident virtual visit log. The facility has fit tested staff since the last visit and procured additional universal sized N95 masks. Care giver staffing and PPE is not a concern. The facility has submitted PPE inventory to the RO and is using the burn calculator. In addition, two staff members were observed donning and doffing successfully today. The facility continues to conduct surveillance testing of 25% of staff and residents weekly. No positives in the facility, the facility is compliant with the RO’s requests and census is 49.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/10/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020
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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