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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/28/2020
Date Signed: 10/29/2020 04:43:12 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: 48DATE:
10/28/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Mary Webster and David WallTIME COMPLETED:
01:00 PM
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LPA Johnson arrived unannounced for a Health and Safety check/ case management inspection. LPA met with Mary Webster and David Wall Administrators. LPA took a tour of the facility.

Resident's in care appear to be safe and there are no health/safety concerns identified. LPA observed 5 staff members on duty during inspection and this appears to be sufficient to meet the needs of the resident's in care. LPA inspected inside and outside of the facility and no health/safety hazards were present. The facility has put into place "stop signs" on the inside of the positive COVID rooms as a reminder to residents not to come out and to request assistance. There is a call system connect through the phones in each resident room, which is connected to the front office switch broad.

Facility is maintained at a comfortable temperature for the residents. The needs of the residents in care appear to be met during LPA's inspection.

LPA briefly interacted with resident's in care, resident's appear to be groomed appropriately and cared for. LPA inspected facility food supplies, food supplies were adequate during LPA inspection. Fire prevention services including fire extinguishers, ansul systems and class K extinguishers are current. Surveillance testing has been completed for 10 residents, no results at this time.

No deficiencies cited were observed during this case management inspection.

Exit interview conducted.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2020
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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