380540203-1-4-2021-14-AS-LKIG-BWXNEH-20210104092359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 12/09/2020
Date Signed: 01/04/2021 09:26:18 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 HOUSE		FACILITY NUMBER:	380540203
ADMINISTRATOR:	WALL, DAVID		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS:	DATE:	12/09/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Hazel Castro, Admin		TIME COMPLETED:	04:06 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 9, 2020, Licensing Program Manager (LPM) Liza King, and Barbie Hensen, HFEN conducted an announced case management visit via Microsoft Team. The team met with David Wall, Licensee /Administrator, Diana Wall IP, RN, Tangi Paama, IP and Hazel Castro, Admin and Angelina Guzman, Admin. Current census 49; 1 resident currently on hospice (stable), the facility has no active Covid positive residents or staff. The team met the new Admin today during her orientation. Discussed the safe practices and longevity of staff. The facility continues to conduct surveillance testing on residents. Surveillance testing of residents and staff this week completed. Mass testing results from last week of all staff resulted in no positive. NO staff or residents reporting any s/s. For the holidays no families insisted on taking their loved ones out of the facility for the holiday. During the tele-visit, the team toured the facility viewed the Ombudsman poster, CCL poster and personal rights poster, the activity area that had the small tables with socially distanced chairs, 6 ft distancing posters throughout, proper signage in the bathrooms, no touch trash cans, soap dispensers and paper towels, reminder poster for staff to wear masks and wash their hands. The entry area, the front door is always closed, staff screening area was explained by the new Admin incl the questionnaire and dirty clean side of where pens and clip boards are placed, the facility continues to have a designated staff member. HFEN asked the facility when the last positive was, Aug. 2020 the facility cont to not have communal dining per the LHD guidance.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

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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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: 12/09/2020

NARRATIVE

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Amy and Annette are the new LHD contact for the facility. HFEN asked if residents are doing online shopping, the AC is coordinating with families, and online shopping. Tour of the facility staff break tables that include outside sitting area was observed, wipes and cleaning policy were present on all table tops, also viewed was a cell phone ultraviolet light that the facility got for staff to disinfect their phones as they enter the facility, balcony area was viewed cleaning products and procedures on tables. Elevator area was observed, HFEN recommended no more than 2 people in the elevator at a time signage. Meal prep area observed, P&P present as was the sit time for cleaning product on outside of bottle. Stair case with evac chair and multiple signage throughout. Entry into the COVID area clean side, viewed PPE area, staff breakroom, posted and laminated mitigation plans throughout. The staff will enter the clean area, put their belongings away in the break room, exit to PPE area, observed mock donning by IP then entered into the positive area. Entry into a positive room showed the signage in the bathroom, paper towels, soap and a garbage can. If a resident has dementia the facility will ensure that a wall mounted soap dispenser will be placed in the room as well has no hand sanitizer left in the room. Leaving the COVID area was also witnessed including a mock doffing of PPE
No concerns were noted.

No deficiencies were observed during today’s call. Exit interview was conducted with Hazel Castro, Admin where LPM reviewed report with Hazel 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 Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020

LIC809 (FAS) - (06/04)

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