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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/25/2024
Date Signed: 10/25/2024 01:51:47 PM

Document Has Been Signed on 10/25/2024 01:51 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BUENA VISTA MANOR HOUSEFACILITY NUMBER:
380540203
ADMINISTRATOR/
DIRECTOR:
ANGELINA GUZMANFACILITY TYPE:
740
ADDRESS:399 BUENA VISTA EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY: 87TOTAL ENROLLED CHILDREN: 0CENSUS: 67DATE:
10/25/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:27 AM
MET WITH:David Hall, Executive Director & Hazel Castro, Co-AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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On 10/25/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Front Desk Staff, Elizabeth Palle. Executive Director, David Wall and Co-Administrator, Hazel Castro were contacted and arrived later in the visit. The facility currently provides care for 67 residents, 7 of which are receiving hospice services and some of which with a diagnosis of dementia.

LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged. Smoke and carbon monoxide detectors and fire safety systems were present and serviced by fire inspection agency within the year. Additional inspection is expected to be completed in the following month.

There was a sufficient supply of both perishable and nonperishable foods as required, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished constantly throughout the week and stored properly. Facility provides a variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. The facility is equipped with two elevators, one of which is currently under service awaiting additional parts for repair. There is still one elevator that is fully operational for resident use.

Residents that were out in the community during the inspection were observed interacting with staff, fellow residents and visitors in the common areas. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents are encouraged to participate in activities, well observed during the tour. Residents were also observed to have a positive and personable relationship with staff and Executive Director. There is a large garden area equipped with appropriate shading and two additional outdoor balcony patios for resident use.
Continued onto LIC809-C
Andrea MedlinTELEPHONE: (650) 266-8811
Dominic TobolaTELEPHONE: (650) 393-9128
DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/25/2024
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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BUENA VISTA MANOR HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 10/25/2024
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LPA conducted a sample file review for residents and 4 out of 5 residents require updated appraisals. Technical Violations issued. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training completed. Lastly, A spot check of medications was conducted and found that all medication counts and records to be in order.

Angelina Guzman's Administrator Certificate is currently active through 7/17/2025.
LPA requested the following documents be sent to CCL by COB 11/8/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 10/25/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2024
LIC809 (FAS) - (06/04)
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