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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/06/2021
Date Signed: 10/06/2021 12:29:15 PM

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:
10/06/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:David and Diana WallTIME COMPLETED:
12:45 PM
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On 10/06/2021 at 1045 Licensing Program Analysts (LPA) Jaime Vado and Murial Han conducted an unannounced case management - Legal/Non-compliance inspection. LPAs met with David Wall and Diana Wall

During today's inspection visit LPAs made observations within the facility with both David and Diana. This is a five floor facility. Residents reside through out all floors. Upon entrance to the facility that is considered the second floor. PPE storage room is located on this floor adjacent to front desk area. PPE is in place. COVID check in procedures are in place. LPAs observed seating areas and specific seats are marked to show which are allowed to sit in adhering to the six foot distancing policy. Exterior balcony also observed with similar seating arrangements. Dining room is observed as well with six foot rule in place. Cleaning schedule and procedure was observed as in place. Group activity room is observed on this floor as well as taking place with social distancing being practiced and residents are masked. Multiple hand sanitizing stations are observed as in place. Third floor is observed and COVID isolation area is located on this floor. Seven rooms are designated for COVID positive. Room 3106 is observed as equipped with required CDSS furniture, a private bath, individual PPE, trash cans for doffing and trash cans with tight fitting lids are present. COVID signs encouraging social distancing, hand washing, and masking observed through out entire facility and bathrooms.


Continued on next page.

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SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 10/06/2021
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Case Management - Legal/Non-compliance


Records are reviewed for staff and residents. Records reviewed indicate that facility is training staff, new and current, in the the items outlined in the Stipulation Waiver and Order issued in Section 2 part A. Training records show that staff are trained annually in the topics outlined in Section 2 part B. In accordance to Section 2 part C there are co-administrators in place. In accordance to Section 2 part D, LPAs discussed the regular assessment of residents to ensure that facility is appropriate setting for those residents assessed and when necessary to evict the facility understands it will follow proper eviction procedures under Title 22, Code of Regulations, section 87224. Under section 3 part B David Wall agreed to begin the required training outlined in this section during the second year of probation.


Report is reviewed with David Wall.

No citations issued.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2021
LIC809 (FAS) - (06/04)
Page: 2 of 2