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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/13/2020
Date Signed: 10/13/2020 05:45:37 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: 49DATE:
10/13/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:David WallTIME COMPLETED:
05:45 PM
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On 10/13/20 Licensing Program Analyst (LPA) Chris Hopkins conducted a case management tele-inspection and Technical Assistance to follow up on non compliance conference via telephone dated 9/30/20. Health Facilities Evaluator Nurse (HFEN) Barbie Henson was present on the tele-inspection. LPA and HFEN met with Administrator David Wall and Diana Wall RN/PHN.

During the tele-inspection LPA observed all 4 caretakers on duty donning and doffing PPE. Each caretaker provided LPA and HFEN demonstrations of donning and doffing. Caretakers still need more training on the process, and LPA informed Diana Wall that all caretakers on each shift should get thorough training. HFEN advised Diana Wall to go to CDC website and print a copy for each caretaker on donning and doffing procedures.

No deficiencies cited today

This report was reviewed with Administrator David Wall and a copy of this report was emailed to him for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2020
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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