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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/09/2020
Date Signed: 10/09/2020 06:10:44 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:
10/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Diana Wall and David WallTIME COMPLETED:
05:30 PM
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On 9/29/20 Licensing Program Analyst (LPA) Chris Hopkins conducted a case management tele-visit for Technical Assistance.

LPA was given a tour of the facility by Diana Wall. LPA observed each floor as well as the entrance. LPA observed a staff screening a visitor, the staff was wearing proper PPE. LPA then observed EMT sitting in the main room with proper PPE. Diana Wall then showed LPA to the kitchen and LPA observed kitchen staff wearing mask and gloves. LPA observed floors G-4 all having 2 designated PPE stations. Staff on each floor had on proper PPE which includes masks, gowns, face shields, and gloves. Each residents door has a reminder for staff about PPE. Per Diana Wall PPE is checked hourly.

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

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
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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