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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 07/07/2021
Date Signed: 07/08/2021 09:31:35 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: 0DATE:
07/07/2021
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David Wall and Diana WallTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michael Garcia, Licensing Program Manager (LPM) Julio Montes, and Regional Manager (RM) Vivien Helbling conducted a collaborative tele-visit meeting with facility co-administrator David Wall, along with facility infection prevention nurse Diana Wall, RN, BSN.

During the meeting, RM Helbling went over and elaborated each item of the Stipulation and Waiver; And Order (“Stipulation”) that was effective on June 18, 2021.

Prior to this meeting, the vendor/trainer submitted by facility for evaluation was approved by RM Helbling.

Questions from meeting participants, including questions regarding training, were answered by RM Helbling and LPM Montes. All meeting participants stated that they understood the Stipulation at the end of the meeting.

RM Helbling confirmed that the Department’s transparency website has been updated to reflect the probationary status of the facility.

David Wall agreed to submit a copy of the facility’s most updated Personnel Report (LIC500) to the licensing office, attention LPM Montes, by end of business day tomorrow, July 8, 2021.

No deficiency cited during this visit. This report was reviewed with David Wall, co-administrator, and a copy of this report was provided electronically for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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