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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 02/15/2023
Date Signed: 02/15/2023 12:28:45 PM


Document Has Been Signed on 02/15/2023 12:28 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:
02/15/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator, Angelina GuzmanTIME COMPLETED:
12:40 PM
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On 2/15/2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced Case Management - Legal/Non-compliance visit. LPA was properly screened by the receptionist. LPA met with Administrators, Angelina Guzman, co-administrator David Wall and Infection Control Preventionist Diana Wall..

During the facility tour, LPA observed COVID-19 signs are posted by the main entrance and round the facility. LPA observed residents in the activity room were wearing face mask and practicing social distancing. Multiple hand sanitizing stations are observed as in place. The tables and chairs in the dining room and activity room remain 6" apart. Kitchen appeared to be cleaned, and tidy. The refrigerator temperature observed to be at 38 degrees Fahrenheit and freezer was at -4 degrees Fahrenheit. Hand-washing instruction is posted by the kitchen sink.

The public bathrooms are equipped with liquid soaps, paper towel, trash cans with lids and hand washing instruction posters. The water fountains are taped off with a sign stating "Do Not Use". LPA observed individual infection control stations were set-up in the hallway through-out the facility.

LPA reviewed infection control training records, and daily COVID-19 screening records for visitors, staff and residents.

No deficiency cited today. This report is reviewed and discussed with the Administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2023
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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