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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 10/23/2020
Date Signed: 10/26/2020 03:29:11 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:
10/23/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:David WallTIME COMPLETED:
04:00 PM
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On 10/23/2020, Licensing Program Analyst (LPA) Albert Johnson, Licensing Program Manager (LPM) Liza King, Program Clinical consultant Paul Portem, Health Facilities Evaluator Nurse (HFEN) Barbie Henson, Regional Manager (RM) Krystall Moore, Assistant Program Administrator (APA) Stacy Barlow and San Francisco Public Health (SFPH) representative Sammi Truong, Benson Nadell and Julie Schneider (Ombudsman) conducted an announced case management visit. The team met with Administrator David Wall, Infection Preventionist Tangi Paama and Diana Wall, RN,BSN,PHN,IP.

During the tele-visit, the team toured the outside sitting area, dining prep area, kitchen and three residents rooms on three levels and the memory care area. Also observed during the tour was a caregiver who demonstrated Personal Protection Equipment (PPE) donning and doffing procedures.

The HFEN confirmed that the staff performed well with the donning and doffing of Personal Protection Equipment (PPE). The facility has posted signage in all areas of the facility including the elevators. Suggestion were made by the HFEN to have a "stop sign" on the inside of the positive COVID rooms as a reminder to residents not to come out and mobile carts for isolation areas with writing on the outside to identify inventory.

As of right now the facility is only allowing essential workers into the facility. They were advised to not have communal dining or group activities until the local health department reviews the plan. The plan has been received and will be reviewed with recommendations if needed.
SUPERVISOR'S NAME: Anthony PerezTELEPHONE: (916) 263-752
LICENSING EVALUATOR NAME: Albert JohnsonTELEPHONE: (916) 217-1390
LICENSING EVALUATOR SIGNATURE:

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/23/2020
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The Department will continue tele-visits three times per week with one of the days unannounced including a nurse via Microsoft Teams.

The mitigation plan and training plan has been received and is being reviewed. Weekly staffing schedules have been requested by the Department and to send a new schedule if changes occur.

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.

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

DATE: 10/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/23/2020
LIC809 (FAS) - (06/04)
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