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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 380540203
Report Date: 07/09/2025
Date Signed: 07/09/2025 12:16:48 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/10/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250410115703
FACILITY NAME:BUENA VISTA MANOR HOUSEFACILITY NUMBER:
380540203
ADMINISTRATOR:ANGELINA GUZMANFACILITY TYPE:
740
ADDRESS:399 BUENA VISTA EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:87CENSUS: 69DATE:
07/09/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:David Wall, Executive DirectorTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Lack of supervision resulting resident falling off bed
INVESTIGATION FINDINGS:
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On 7/9/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, David Wall. LPA toured the facility, interviewed Executive Director, reviewed resident records and made observations during the course of the investigation.

Complaint alleges lack of supervision resulting in resident (R1) falling off bed. Upon review of resident records R1 had previously ambulated with the use of a walker. On 4/7/2025, (R1) had been prescribed a wheelchair for fall prevention. The response to the change of condition was prior to the alleged event. In addition, Executive Director indicated that further fall prevention items including lowered bed frame and fall mats implemented. During multiple visits and facility tours, LPA observed a sufficient amount of caregiver staff and additional support staff on each floor.

Continued onto LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20250410115703
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUENA VISTA MANOR HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 07/09/2025
NARRATIVE
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Lastly, upon review of photo evidence provided of R1, LPA found that there is not a clear indication of any signs of distress or injury or R1 to have fallen. Due to a lack of corroborating evidence the allegation is found to be unsubstantiated.

A finding that the complaint allegation lack of supervision resulting resident falling off bed is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiency cited.
SUPERVISOR'S NAME: April Cowan
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2