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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/20/2020
Date Signed: 10/20/2020 03:33:53 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:
10/20/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:David WallTIME COMPLETED:
02:30 PM
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A case management tele-visit was held on 10/20/20 to follow up on positive Covid-19 residents and mitigation plan for the facility, the visit was conducted via tele-visit and scheduled with licensee due to COVID-19 and precautionary measures. Present at the tele-visit were Administrator, David Wall, Elizabeth Hampton, President, and Legal Counsel, Denise Isfeld, Barbie Henson (California Department of Public Health), Diana Wall, RN,BSN,PHN,IP. Licensee, Infection Preventionist Tangi Paama and department personnel: Regional Manager Krystall Moore and Vivien Helbling, Licensing Program Managers (LPM) Liza King, Julio Montes, Licensing Program Analyst (LPA) Albert Johnson, Clinical support, Paul Portem and Myra Cunanan, Assistant Program Administrator Stacy Barlow.

This meeting is to discuss the needed revisions to the mitigation plan and ensure guidance regarding containment and mitigation is being followed. The team has requested changes to the mitigation plan to adjust corrections, spelling etc.. The facility agreed to have the revised plan submitted to the Sacramento South Regional Office team by COB 10/22/2020.

The Department has requested clear training logs to include: times, signatures and content of the training. Additional training will include recording of donning and doffing PPE, and N-95 mask. The Department recommending to use CDC video for training for staff.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
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 HOUSE
FACILITY NUMBER: 380540203
VISIT DATE: 10/20/2020
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The Department has requested a plan of correction with measurable, attainable and identifiable terms regarding training of staff per the citation issued on 10/19/20.
The facility has put into place signs and posted the donning and doffing sequence signage, hand sanitizer has been placed in all rooms and demonstrations rooms, PPE station on all floors with garbage cans inside and outside of rooms. The facility will be using disposable gown in the positive COVID rooms and reusable gown in the non-positive rooms.

The Infection Preventionist nurse will be in the facility 40 hours per week for Infection Control, surveillance, training and creating policies for COVID related issues. She will also do real time training and ensure application is being applied when on the floor. Surveillance testing is occurring.

The facility is no longer admitting residents at this time (since March), has hired a new Administrator (Mary Webster) who starts tomorrow 10/21/2020 and a second Administrator will be hired. The facility will send copies to the Sacramento office for all incidents reported.

The Department will continue tele-visits three times per week with one of the days unannounced including a nurse. The facility agreed to submit weekly staffing schedules.

No deficiencies were observed during today’s call. Exit interview was conducted with David Wall where LPA reviewed report with David via telephone. An electronic copy of the report was emailed to the facility to obtain a signature from the administrator and emailed back to LPA to be filed.

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

DATE: 10/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020
LIC809 (FAS) - (06/04)
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