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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 12/02/2020
Date Signed: 01/04/2021 10:29:54 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:
12/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:David WallTIME COMPLETED:
03:00 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 2, 2020, Licensing Program Manager (LPM) Liza King, and Krystall Moore, Regional Manager conducted an announced case management visit via Microsoft Team. The team met with David Wall, Licensee /Administrator, Diana Wall IP, RN
Current census 49; 1 resident currently on hospice, the facility has no active Covid positive residents or staff. The facility continues to conduct surveillance testing on residents. However, since the holiday as a precautionary measure the facility has conducted mass testing on staff to include 38 staff members as of today which is 76% of staff overall. Testing was completed yesterday, results possibly by EOW. NO staff or residents reporting any s/s, no call offs everyone doing well. During the tele-visit, the team toured the staff screening area incl the questionnaire and dirty clean side of where pens and clip boards are placed, the facility continues to follow its mitigation plan, the facility continues to have a designated staff member, restrooms with required signage, outside sitting area on the front patio where residents were observed seated, the community main floor was active with residents about, all pleasant, and socially distanced. All small tables have wipes present for cleaning in main area as on the patio and balcony area. No visitors were observed. The team then went downstairs and observed more residents seated in the main area, socially distanced at tables or seated along the corridors. All residents and staff observed were wearing masks. Entry into one resident bedroom on the lower level, the resident was seated in a wheelchair, answered the bedroom door and returned to reading a magazine. David entered into the bathroom where all the appropriate signage was posted, the team requested that the phone be taken off the hook to alert staff that the resident may need assistance. Staff came to inquire rather quickly (less than one minute response time). The team conducted an unannounced donn and doff of a random staff in the hall whom verbalized every step while conducting the procedure. No concerns were noted. The team observed the COVID WING. All signage is laminated for easy cleaning and the towel dispensers are mounted on all the walls. Entry into one bedroom on this floor all PPE stocked and bedroom ready for move in, signage posted on door and in bathroom. The new Admin is scheduled to start still awaiting COVID testing.
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: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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