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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 12/30/2021
Date Signed: 12/30/2021 03:51:53 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: 43DATE:
12/30/2021
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Angelina GuzmanTIME COMPLETED:
12:00 PM
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On 12/30/2021, Licensing Program Analysts (LPA) Murial Han conducted an unannounced Case Management - Legal/Non-compliance virtual inspection due to COVID-19. LPA met with Administrator, Angelina Guzman, Administrator, Hazel Castro, Co-Administrator, David Wall and Infection Control Preventionist, Diana Wall

LPA was provided a virtual tour by the Infection Control Preventionist, Diana Wall and LPA observed COVID-19 signs were posted by the main entrance, there were several hand sanitizer stands installed and screening logs for the visitors and the facility staff. The public bathrooms were equipped with liquid soaps, paper towel, trash cans with lids and hand washing instruction posters. 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, and the water fountains were taped off with a sign stating "Do Not Use". and individual infection control stations were set-up in the hallway through-out the facility.

During the tour on the 3rd floor designated isolation unit, LPA observed isolation PPE stations, and two trash cans with foot operated lids (one for soiled PPE supplies and the other one for soiled incontinent changes and garbage) were set-up before the entrance. After the entrance, LPA observed isolation PPE stations set-up both inside and outside of each isolation room equipped with PPE supplies, hand sanitizers, alcohol wipes, thermometers and daily COVID-19 screening logs, donning and doffing signs were posted both inside and outside of each room, and the bathrooms were equipped with supplies, and hand-washing signs were posted.

During today's inspection, LPA also reviewed the facility's Medication Management process and the facility explained the documentation procedure for the resident's files.

No deficiency cited today. This report is reviewed and discussed with the Administrators, Co- Administrator and the Infection Control Preventionist. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
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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