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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 12/21/2022
Date Signed: 12/21/2022 06:53:21 PM


Document Has Been Signed on 12/21/2022 06:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



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: 47DATE:
12/21/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Angelina GuzmanTIME COMPLETED:
11:00 AM
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On 12/21/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA was properly screened by the receptionist at front entrance with the COVID-19 questionnaire and the temperature taken. After the screening, LPA was greeted by the Administrator, Angelina Guzman, Infection Control Preventionist, Diana Wall and Co-Administrator, David Wall. LPA explained the purpose of the visit.

LPA reviewed the following documents: daily monitoring and screening for residents and staff (residents are screened daily unless they tested positive for COVID-19 then they will be monitored every 4 hours; staff are being screened at the beginning and the end of their shifts). LPA observed PPE/ COVID-19 training is completed on a monthly basis.

Staff provided a tour of the facility. LPA observed COVID-19 signs are posted by the main entrance, there are hand sanitizer stations through-out the facility. The public bathrooms for the staff and residents are equipped with liquid soaps, paper towels and hand-washing signs indicating the 20 second rule. In the activity and living rooms, LPAs observed residents were wearing masks, and tables were 6" apart. The water fountains are continued to be 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 elevator has COVID-19 signs posted both inside and outside and hand sanitizer station is installed next to the elevator. Individual infection control stations were set-up in the hallway through-out the facility.

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. Donning and doffing signs are posted by each room.

SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/21/2022
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUENA VISTA MANOR HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 12/21/2022
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Medications are stored appropriately and inaccessible to residents, a comfortable temperature is maintained, lighting is sufficient for comfort. First-aid kit is inspected and complete.

No deficiency cited today. This report is reviewed and discussed with the Administrator, Co- Administrator and the Infection Control Preventionist. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 12/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022
LIC809 (FAS) - (06/04)
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