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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 06/20/2023
Date Signed: 06/20/2023 01:40:33 PM


Document Has Been Signed on 06/20/2023 01:40 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:
06/20/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrators, Hazel Castro and Angelina GuzmanTIME COMPLETED:
01:50 PM
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On 6/20/2023, Licensing Program Analysts (LPA) Murial Han conducted an unannounced Case Management - Legal/Non-compliance visit. LPA completed the passive COVID-19 screening at the front desk. LPA met with Administrators, Hazel Castro, Angelina Guzman and, co-administrator David Wall. LPA explained the purpose of the visit.

During today's visit, LPA review staff training records in the areas of Observation and Assessment of Residents, Residents' Personal Rights, Reporting Requirements, Types and Symptoms of Infectious Diseases, and Prevention/Mitigation and Care of Residents with Infectious Diseases and LPA observed records to be sufficient.

During the facility tour, LPA observed COVID-19 signs are posted by the main entrance and around the facility. Facility appeared to be cleaned and tidy. Residents in the living room mingling with each other. Activity room was set up for an activity.

Multiple hand sanitizing stations are observed. Kitchen storage room appeared to be cleaned, and tidy. The walking refrigerator temperature was observed to be at 39 degrees Fahrenheit (F) and freezer was at -0 degrees Fahrenheit(F).

Fire extinguisher was last serviced on Nov 21, 2022. PPE supply is adequate. A comfortable temperature is maintained, lighting is sufficient for comfort and safety.

No deficiency cited today. This report is reviewed and discussed with 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: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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