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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/16/2020
Date Signed: 10/16/2020 05:04:23 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:
10/16/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:David WallTIME COMPLETED:
03:32 PM
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On 10/12/20 Licensing Program Analyst (LPA) Chris Hopkins conducted a case management tele-inspection to follow up on non compliance conference via telephone dated 9/30/20. LPA met with Administrator David Wall.

LPA followed up on recommendations made by Health Facilities Evaluator Nurse (HFEN). Those recommendations included: Training on the CDC Sequence of PPE and CDC signage to be posted or used in training, hand washing signage at all hand washing basins, and providing hand sanitizer inside Covid+ rooms and a foot operated lidded trash container.

LPA observed the following:
-Hand washing signage in ground floor rooms (Rooms 5001, 5002, 5004, 5005, 5007)
-2 staff demonstrating donning and doffing PPE procedures based on CDC sequence
-Hand sanitizer in Covid+ ready rooms (Rooms 3013, 3014, 3005)
-Foot operated trash cans in residents rooms

Administrator also provided copies of in-service PPE training logs from 10/13/20, 10/14/20, and 10/15/20. San Francisco Department of Public Health will be providing Buena Vista with masks, gowns, and gloves.

No deficiencies cited today

This report was reviewed with Administrator David Wall and a copy of this report was emailed to him for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2020
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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