380540203-10-6-2021-14-AS-MHAN-C7JR2G-20211006123818

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/06/2021
Date Signed: 10/06/2021 02:35:51 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 HOUSE		FACILITY NUMBER:	380540203
ADMINISTRATOR:	WALL, DAVID		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS: 47	DATE:	10/06/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Co-Administrators, Angelina Guzman and David Wall		TIME COMPLETED:	12:50 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 10/6//2021, Licensing Program Analyst(LPA) Murial Han and LPA Jaime Vado conducted an unannounced annual inspection. LPAs were properly screened by the receptionist at front entrance with the COVID-19 questionnaire and the temperature. After the screening, LPAs were greeted by the Administrator, Angelina Guzman and Co-Administrator, David Wall. LPAs explained the purpose of the visit. LPAs reviewed the following documents: daily monitoring and screening documents for residents and staff (residents are being screened twice a day- AM and PM and staff are being screened as they arrive and when they leave), training records, and COVID-19 testing records and schedule. After reviewing the records, LPAs started with a tour of the facility that was led by the Infection Control Preventionist/Public Health Nurse, Diana Wall along with the Administrators, Angelina Guzman and Hazel Castro and Co- Administrators, David Wall, LPAs observed COVID-19 signs were posted by the main entrance, there were several hand sanitizer stands installed. The public bathrooms for the staff and residents were equipped with liquid soaps, paper towels and hand-washing signs indicating the 20 second rule. LPAs observed residents were wearing masks and maintaining social distancing in the Activity room, the couches and the benches are marked off appropriately to ensure social distancing is maintained. There were hand wipes and hand sanitizer bottles placed on many of the tables, all the trash cans were observed to have foot operated lids, the water fountains were taped off with a sign stating "Do Not Use", the dining room observed to be cleaned and the tables were at least 6" apart. The dining room staff demonstrated the equipment and high touched areas such as the food carts, the tables, the door knobs, etc. that are being sanitized every 4 hrs along with a log showing who and when those cleaning tasks were performed. The elevator has COVID-19 signs posted both inside and outside and hand sanitizer stand was installed next to the elevator. Individual infection control stations were set-up in the hallway through-out the facility.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
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)

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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

NARRATIVE

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After the tour on the 2nd floor, we continued onto the 3rd floor that the facility has designated it as to be the COVID-19 unit. LPAs observed closed lid trash cans were placed in front of each room, donning and doffing and other COVID-19 signs were posted on both inside and outside of the doors, the bathrooms were equipped with liquid soaps, and hand-washing 20 second signs. LPA recommended to remove the cloth towels in the bathrooms.

The facility has 2 PPE supply stock rooms- one on the 2nd floor and one on the 3rd floor. The facility is well equipped with supplies. The staff members who are designated to work in the COVID-19 unit, has their own assigned PPE supplies stocked in a container with their names on it.

No deficiency cited today. This report is reviewed and discussed with the the Administrators, Co- Administrator and the Infection Control Preventionist. A copy is provided.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
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)

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