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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540203
Report Date: 09/29/2020
Date Signed: 09/29/2020 04:34:14 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:
09/29/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:David Wall TIME COMPLETED:
05:00 PM
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On 9/29/20 Licensing Program Analyst (LPA) Chris Hopkins made a case management tele-visit regarding a previous complaint investigation (complaint # 14-AS-20200728121542). LPA met with Administrator David Wall and explained the nature of the tele-visit.

During the investigation of complaint 14-AS-20200728121542, filed on July 28, 2020, the Department found the following:

A resident (R1) went to the hospital on 7/24/20. Upon discharge, the licensee refused to accept the resident back based on the facility administrator’s personal belief that the resident needed higher level of care. The licensee failed to follow eviction procedures, relying solely in the administrator’s personal assessment rather than an appropriate medical assessment to determine that a resident was beyond the level of care. The evidence available indicates that the administrator lacks the knowledge of the requirements for providing care and supervision appropriate to the residents, and lacks knowledge of and ability to conform to the applicable laws, rules and regulations.

R1 was admitted on 8/31/15; R1 had a catheter prior to his/her visit to the hospital on 7/24/20; as per Section 87623, a licensee is permitted to accept or retain a resident who requires the use of an indwelling catheter as long as the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. The Administrator indicated to R1’s responsible party that the resident had become “dead weight” and physically and/or mentally unable to care for his condition. There is no evidence that an exception was ever requested or issued between the date of admission and the date R1 went to the hospital. Preponderance of evidence indicates that the licensee failed to request and obtain an exception to care for the resident between the time of admission and the time the resident went to the hospital.

Report Continued on LIC809-C...
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020
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: 09/29/2020
NARRATIVE
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 Deficiencies of the California Code of Regulations, Title 22, are cited on the attached LIC809-D. Appeal Rights given. This report was discussed and reviewed with Administrator, David Wall.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
09/30/2020
Section Cited

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87405 Administrator Qualifications and Duties:(d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7)...(1)Knowledge of the requirements for providing care and supervision appropriate to the residents. (2)Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
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Based on observations and record reviews, the licensee did not ensure that the Administrator had knowledge of Title 22 regulations regarding Eviction Procedures which poses an immediate health, safety, and personal rights risk to persons in care.
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Request Denied
Type A
09/30/2020
Section Cited

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87623 Indwelling Urinary Catheter: (a)The licensee shall be permitted to accept or retain a resident who requires the use of an indwelling catheter under the following circumstances:(1)If the resident is physically and mentally capable of caring for all aspects of the condition except insertion and irrigation. This requirement is not met as evidenced by:
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Based on observation, interviews, and record reviews the licensee did not ensure that the resident (R1) was physically and mentally capable of caring for all aspects of the condition which poses an immediate health, safety, and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2020
LIC809 (FAS) - (06/04)
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