<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 11/25/2020
Date Signed: 01/04/2021 09:27:55 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:
11/25/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David WallTIME COMPLETED:
11:56 AM
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 November 25, 2020, Licensing Program Manager (LPM) Liza King, and Health Facilities Evaluator Nurse (HFEN) Barbie Henson conducted an unannounced case management visit via Microsoft Team. The team met with David Wall, Licensee /Administrator.
Current census 49; 1 resident currently on hospice, the facility has no active Covid positive residents. During the tele-visit, the team toured the staff screening area incl the questionnaire and confirmation that staff are temped two times a day, restrooms with required signage, outside sitting area on the front patio where residents were observed seated, the entry area with the Christmas Tree and three residents walking around engaged, pleasant and neatly dressed, the meal prep area including the cleaning P&P’s and disinfectant, the staff break area to include the P&Ps and disinfecting wipes, the kitchen area including all of the required signage and a trash placed under a counter. The team observed the COVID WING consisting of 9 private rooms. All signage is laminated for easy cleaning and the towel dispensers are mounted on all the walls. All PPE is stocked. The COVID area break room was also observed, including the laminated signage in English and Spanish (throughout the facility). All requested modifications and/or items have been provided promptly.
As of right now the facility is still only allowing essential workers into the facility. They have communal dining and group activities projected to start in the near future. Weekly staffing schedules have been provided, as have all requested documents, weekly reports, calendar activities, including facetime visits and visitor scheduled visits in outdoor area.
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: 11/25/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020
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 1