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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/13/2020
Date Signed: 01/04/2021 09:30:21 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:
11/13/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:David WallTIME COMPLETED:
02:45 PM
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On November 13, 2020, Licensing Program Manager (LPM) Liza King and Program Clinical Consultant Paul Portem conducted an announced 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, seating area at entry, two Assisted Living resident bedrooms and restrooms. Residents observed, were engaged in conversation, one doing a crossword the other ambulating around the room. Also observed seated in the entry area of the facility was a 102year old gentleman in good spirits who showed us how to exercise. While in the COVID designated area, the team observed all previous guidance being followed. Also observed was the kitchen area including the dry food storage, refrigerator and freezer, no concerns were noted. Observation of kitchen staff washing their hands occurred per the request of the HFEN. A new addition throughout the building is laminated hand washing signs with pictures in english and spanish. In addition, during the tour the electricty went out, the facility Department observed the emergency lighting and fire doors shut. The facility has hired two new Administrators, start date approx 2 weeks. The RO has received the inventory list and burn calculator as requested, training logs and virtual visits. There are no residents on hospice and all are reportedly doing well. Caregiver staffing and PPE are not a concern. 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. The facility would like follow up provided on admissions. Census is 49.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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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