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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 12/17/2020
Date Signed: 01/04/2021 09:23:10 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:
12/17/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:David Wall TIME COMPLETED:
05:00 PM
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On December 9, 2020, Licensing Program Manager (LPM) Liza King, Barbie Hensen, HFEN, Julio Montes LPM, Christopher Hopkins-Clark, LPA, Vivien Helbling, RM, and Krystall Moore, RM conducted an announced case management visit via Microsoft Team. The team met with David Wall, Licensee /Administrator, Tangi Paama, IP, Hazel Castro, Admin and Angelina Guzman, Admin.

Current census 48; 1 resident currently on hospice (stable), the facility has no active Covid positive residents or staff. One resident sent to hospital yesterday, fall at the community s/p hip fx, SIR was sent in according to licensee. During the tele-visit, the team toured the front patio area including the tables for staff to break at and visiting area on the patio, at the front door the team observed the screening area for staff and guests, the telephone sanitizing area, the appropriate signage posted, one community restroom with the appropriate signage and necessary soap and paper towels. The team then viewed the small activity / dining area where small tables were socially distanced, the clean gown area for staff, the elevator with the appropriate signage and the large dining area that included staff break areas with P&P present as well as disinfecting supplies, the dinning cart area with the P&P present for cleaning and disinfecting and food service supplies. Upstairs on the 3rd floor the team observed the COVID wing with all practices in place as previously discussed and as they relate to the Mitigation Plan. Staff present were wearing masks and showed knowledge of the procedures.

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 MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 12/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2020
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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