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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/04/2020
Date Signed: 01/04/2021 09:08:30 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:
11/04/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David WallTIME COMPLETED:
11:50 AM
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On November 4, 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, Infection Preventionist Tangi Paama and Diana Wall, RN,BSN,PHN,IP.

During the tele-visit, the following areas were observed: the designated COVID positive area, hand washing stations and staff break areas. Also observed during the tour was one caregiver who demonstrated Personal Protection Equipment (PPE) donning and doffing procedures. While in the COVID designated area, the team observed the PPE supply closet, STOP signs on the interior of the resident room doors, PPE stations throughout, wall mounted towel dispensers near the PPE areas, foot pedal trash cans, and a newly installed plastic barrier. Observation of the break areas, included new signage of cleaning procedures and readily available disinfectant wipes for staff eating areas and additional assigned break areas, including a break area in the COVID positive area. Observation of three hand washing stations was completed, one of which did not have the recommended signage in a staff break area, recommendations by HFEN were provided to ensure proper hand washing signage be posted near basins.

The Department reviewed and discussed Appendix #2 of the Mitigation Plan and requested changes to be made addressing housekeeping needs in the COVID designated area and the increased risk of additional staff entering and exiting the area. The facility representative Diana Wall addressed the concerns stating that the housekeeping duties will be provided by the caregivers working in the positive area. Changes to the Mitigation Plan to reflect this will be submitted to the RO by 10am on Thursday November 5, 2020. The RO provided guidance if the facility were to utilize housekeeping staff, the staff should be designated housekeeping staff for the COVID area and additional training should be provided to these individuals including but not limited to existing policies and procedures, PPE donning and doffing and universal precautions.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: BUENA VISTA MANOR HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 11/04/2020
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During the visit there was also conversation about the prospective Administrator applicants that will be vetted by the Department. The RO has also requested applicant package be submitted to the RO by end of day on Wednesday, November 4, 2020.

Lastly, N95 mask inventory was discussed. The facility has 210 masks of which 180 have been assigned and stocked in supply drawers in the COVID area. For this reason, the supply readily available is 30. The RO has requested that the facility representatives reach out to the LHD by end of day November 4, 2020 and inquire if additional supplies are available.

No deficiencies were observed during today’s call. Exit interview was conducted with David Wall where LPM reviewed report with David via telephone. An electronic copy of the report was emailed to the facility to obtain a signature from the Administrator and emailed back to LPM to be filed.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020
LIC809 (FAS) - (06/04)
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