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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 06:17:09 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
09/03/2020 and conducted by Evaluator Christopher Hopkins-Clarke
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20200903140811
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:
07:00 PM
ALLEGATION(S):
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-Physical changes to the facility layout without the proper notification and clearance
-Residents being locked in their rooms
-Facility failed to report changes
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 physical changes to the facility layout, the original facility sketch submitted for licensure does not match the current sketch. The facility consists of a ground level and four floors. In the original sketch, the ground level shows open space and separate stalls or small rooms for maintenance; while the newer sketch ground level shows that new construction open area has been replaced with a laundry area, salon, and break room. A new fire clearance has been requested. Based on the information that has been presented, there is preponderance of evidence that a reporting requirement violation has occured.

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 4
Control Number 14-AS-20200903140811
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 residents being locked in their rooms, According to observations by SFDPH staff, during their initial visit on August 4, 2020, two residents were found in the designated isolation area (third floor). There was no staff readily available to attend to the needs of the residents on the floor. One resident appears to have been able to lock himself/herself in the room, and the other resident was non-ambulatory, unable to leave the room. Staff acknowledged that the residents are able to lock themselves in the rooms but denied that a resident had been purposely locked in the room. Staff acknowledged that due to the pandemic, staff checked on the residents through the window. Based on this information, there is preponderance of evidence that residents’ personal rights were violated when the residents were left unattended and unable to exit their rooms.

Regarding the allegations of facility failed to report changes, this allegation refers to the facility providing different and inconsistent information regarding the Covid-19 outbreak, resulting in inaccurate reporting and delayed responses. The 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. 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.

Based on LPAs observations 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
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 4
Control Number 14-AS-20200903140811
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)
Deficiency Dismissed
Type A
09/15/2020
Section Cited
CCR
80022(a)(b)(7)(8)(A)
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80022(a)(b)(7)(8)(A) Plan of Operation:(a) Each licensee shall have and maintain on file a current, written, definitive plan of operation. (b) The plan and related materials shall contain:(7) a sketch of the building to be occupied, including floor plan...This requirement is not met as evidenced by:

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Administrator has agreed to update facility sketch and submit it to CCLD.

Proof of correction must be received by CCL office no later than due date (9/15/20)
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Based on observation the administrator did not ensure that the facility sketch was up to date which poses a potential health, safety, and personal rights risk to persons in care.
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Deficiency Dismissed
Type A
09/15/2020
Section Cited
CCR
80072(a)(7)
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80072 Personal Rights (a)...each client shall have personal rights which include...(7)Not to be locked in any room, building, or facility premises by day or night. This requirement is not met as evidenced by:
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Administrator has agreed to remove locks from doors if necessary, and resident would not be able to lock door from the inside.
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Based on observation by SFDPH, the administrator did ensure residents were able to get out of their rooms, which poses a potential 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: 3 of 4
Control Number 14-AS-20200903140811
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
87405
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87405 Administrator Qualifications and Duties: All facilities shall have a qualified and currently certified Administrator...and shall be on the premises a sufficient number of hours...This requirement is not met as evidence by:
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Administrator has agreed to submit documents showing his designated staff has a valid administrators certificate.

Proof of correction must be received by CCL office no later than due date (9/15/20)
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Based on observation the administrator did not ensure coverage by a designated substitute who was accountable was in place, which poses a potential 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 4