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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 05/24/2022
Date Signed: 05/24/2022 12:09:44 PM


Document Has Been Signed on 05/24/2022 12:09 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
CCLD Regional Office, 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: 44DATE:
05/24/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Angelina GuzmanTIME COMPLETED:
12:15 PM
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On 5/24/2022, Licensing Program Analysts (LPA) Murial Han conducted an unannounced Case Management - Legal/Non-compliance. LPA was properly screened by the receptionist. LPA met with Administrators, Angelina Guzman, and Hazel Castro.

During the facility tour, LPA observed COVID-19 signs are posted by the main entrance, the lobby, the dining room, the hallways on each floor, the staff break room, etc. Multiple hand sanitizing stations are observed as in place. Residents in the dining room are 6" apart from each other with face covering. The tables and chairs in the dining room and activity room are at least 6" apart.

The public bathrooms are equipped with liquid soaps, paper towel, trash cans with lids and hand washing instruction posters. The water fountains were 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.

The 3rd floor is the designated Red Zone. LPA observed isolation PPE stations set-up both inside and outside of each room equipped with PPE supplies, hand sanitizers, alcohol wipes, thermometers, daily COVID-19 screening logs, donning and doffing signs are posted by each room, the bathrooms are equipped with supplies, and hand-washing signs are posted by the sinks. In addition, there is a designated PPE supply room and a designated staff break room with a bathroom inside on that floor.

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: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2022
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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