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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 05/24/2021
Date Signed: 05/24/2021 10:20:07 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 47DATE:
05/24/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Diana WallTIME COMPLETED:
10:20 AM
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On May 24, 2021 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management visit. LPA met with Diana Wall, RN,BSN,PHN,IP and Administrator Dillon Cagulada showed up at a later time.

LPA toured the facility, observing the 3rd floor Covid wing, kitchen/ dining area, main lobby, two PPE rooms that were fully stocked, ground floor, ground floor break rooms and laundry room, and ground floor lobby. LPA observed all staff wearing PPE throughout the facility, which included front desk satff, caretakers, kitchen staff, and the activities director. LPA also observed residents who were out of their rooms wearing face masks as well.

No deficiencies observed today. This report was discussed with Diana Wall RN,BSN,PHN,IP and Administrator, Dillon Cagulada and a copy of this report was provided via email.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2021
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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