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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/12/2020
Date Signed: 10/12/2020 12:17:16 PM

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:WALL, DAVIDFACILITY TYPE:
740
ADDRESS:399 BUENA VISTA EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:87CENSUS: 49DATE:
10/12/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:David WallTIME COMPLETED:
12:15 PM
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On 10/12/20 Licensing Program Analyst (LPA) Chris Hopkins conducted a case management tele-inspection to follow up on non compliance conference via telephone dated 9/30/20. LPA met with Administrator David Wall.

During the tele-inspection LPA observed:
-Screening logs for staff and visitors (with temperatures) (EMT and Public Health nurse signed off on logs)
-Foot operated trash bins in rooms and hallway on 3rd floor
-Hand washing signs in bathrooms of resident rooms on 3rd floor
-Evacuation chair in stairwell
-Laundry room staff wearing PPE
-Staff donning and doffing PPE
-New Infection Preventionist employee
-Staff wearing PPE

The administrator stated the census is 49 as of today 10/12/20. Surveillance testing was done on 10/9/20, still waiting on results. Administrator stated that there will be another surveillance testing done later this week on Friday or Saturday. Administrator agreed to send staffing schedule with new Infection Preventionist and Co-Administrator listed as well as copies of weekly staff training on PPE. There are currently 20 foot operated trash bins on the 3rd floor (Covid floor) with more on order for the rest of the facility. Administrator also stated that there is a cleaning schedule for the walls where PPE are hung outside of each room. Per administrator housekeepers and caregivers are to clean walls in between shifts.

No deficiencies cited today

This report was reviewed with Administrator David Wall and a copy of this report was emailed to him for signature.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2020
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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