Buena Vista Manor House

Type of visit: Case Management - Other

On 7/15/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management in regards to an incident regarding at staff member who was reported to have hit a resident that occurred in January 2026. LPA Calandra was greeted by Angie Guzman, Co-Administrator and explained the purpose of the visit. During the visit, LPA reviewed S1's personnel file and conducted interviews. LPA collected the following documents; -Staff contact information -Staff schedule for the week of 7/18/2026 No deficiencies cited during today's visit. An exit interview was conducted and a copy of the report provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 15, 2026

Type of visit: Case Management - Incident

On 07/13/2026, Licensing Program Analyst(LPA) Yi Sam Jian arrived at the facility to conduct a Case Management Visit in response to an incident report submitted to Licensing in which resident R1 was able to leave the facility unassisted on 07/01/2026. LPA was greeted by Administrator, David Wall and explained the purpose of the visit. LPA toured the facility and reviewed documentation. Based on record review, LPA issued a Type B deficiencies for the facility's failure to conduct and document a reappraisal of R1 following a significant change in condition, after the resident demonstrated wandering and elopement behavior, and for resident leaving the facility unassisted. Deficiencies were cited under California Code of Regulations, Title 22, and documented on the LIC 809-D. Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted with the Administrator. This report was reviewed with the Administrator, and a copy of the report, along with Appeal Rights, was provided to the facility representative.the state’s words, verbatim · CDSS document, Jul 13, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87463(b) · Plan of correction due date: Jul 23, 2026

87463 Reappraisals (b) The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition, including those required to be documented as specified in Section 87466, Observation of the Resident. This was not met as evidenced by facility does not have an updated Needs and Appraisal form since 2022 to document a significant change in condition of R1.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Facility to submit a written plan on how it will address the documentation of reappraisal due to significant changes in of a resident in the facility. Licensee to submit written plan by POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87464(f) · Plan of correction due date: Jul 23, 2026

CCR 87464 (f) Basic services...(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code 1569.2(c) "Care and supervision" means the facility assumes responsibility for...the resident’s physical health, mental health, safety... Based on the file reviewed and interviews conducted, the facility did not ensure basic services were being met. In addition, it was indicated that R1 has a history of AWOL. Due to lack of supervision, R1 AWOL.the state’s words, verbatim · CDSS document, Jul 13, 2026

Plan of correction: Facility to submit a written plan on how it will address the wandering risk of resident in the facility. Licensee to submit written plan by POC due date.

Allegation investigated: Resident sustained injury while in care

On 05/13/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with co-administrator, Hazel Castro, LPA explained the purpose of the visit. Regarding the allegation that Resident sustained injury while in care, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the co-administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 13, 2026 · control 14-AS-20260218115819

Type of visit: Case Management - Incident

On 05/13/2026, Licensing Program Analyst (LPA) conducted an unannounced case management visit regarding an incident that occurred on 03/19/2026. LPA met with Co-Administrator, Hazel Castro, and explained the purpose of the visit. The facility reported that on 03/19/2026, resident R1’s case manager, C1, notified the facility that R1’s lockbox containing medications and jewelry was missing from R1’s room. Case manager C1 filed a police report, and the San Francisco Fire Department (SFFD) responded and interviewed resident R1. During the visit, LPA interviewed Co-Administrator. Co-Administrator reported that Administrator David Wall is conducting an active internal investigation regarding the incident. No deficiencies were cited during today’s visit. The Department will continue to review the information obtained, and additional follow-up may be conducted as needed. The report was reviewed with Co-Administrator, and a copy was provided to the facility.the state’s words, verbatim · CDSS document, May 13, 2026

Allegation investigated: -Resident was not accorded dignity in their personal relationship with staff member.

On 05/08/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with co-administrator, Angie Guzman, LPA explained the purpose of the visit. Regarding the allegation that Resident was not accorded dignity in their personal relationship with staff member, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the co-administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 8, 2026 · control 14-AS-20260205155224

Allegation investigated: -Staff handled resident in a rough manner -Staff interacts inappropriately with residents

On 05/08/2026 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced complaint inspection to deliver findings regarding the complaint allegations received. LPA met with co-administrator, Angie Guzman, LPA explained the purpose of the visit. Regarding the allegation that staff handled resident in a rough manner, the Department investigated and conducted interviews and reviewed documents, witness accounts from multiple residents, clients and staffs were consistent and corroborated the allegations. Regarding staff interacts inappropriately with residents, the Department investigated and conducted interviews and reviewed documents, witness accounts from multiple residents, clients and staffs were consistent and corroborated the allegations. The Department determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with co-Administrator, and Appeal Rights provided Substantiatedthe state’s words, verbatim · CDSS document, May 8, 2026 · control 14-AS-20260127150741

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: May 18, 2026

Personal Rights of Residents(a)(1)To be accorded dignity in their personal relationships with staff. This requirement was not met, as evidenced by records review, interviews with clients, residents, and staffs indicating that facility staff handled residents in a rough mannerthe state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: The Administrator shall develop and submit a written plan to ensure residents are treated with dignity and respect at all times, including measures to address facility staff rough handling of residents. A copy of the plan shall be submitted to Community Care Licensing (CCL) by the POC due date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: May 18, 2026

Personal Rights of Residents(a)(3)To be free from punishment, humiliation, intimidation. This requirement was not met, as evidenced by records review, interviews with clients, residents, and staffs indicating that facility staff interacted inappropriately with residents.the state’s words, verbatim · CDSS document, May 8, 2026

Plan of correction: The Administrator shall develop and submit a written plan to ensure residents are treated with dignity and respect at all times, including measures to address inappropriate staff interactions with residents. A copy of the plan shall be submitted to Community Care Licensing (CCL) by the POC due date.

Type of visit: Prelicensing

On 10/1/2025, Licensing Program Analyst (LPA) Murial Han an unannounced Pre- Licensing inspection. LPA met with the administrator, David Wall and LPA explained the purpose of today's visit. The administrator provided a tour of the facility, and LPA observed the resident rooms, dining room, activities rooms, kitchen and common areas to be cleaned and at a comfortable temperature. All passageways were free of obstruction. Fire Extinguishers located on each resident floor, kitchen and common spaces were last inspected on 3/6/2025. Smoke and carbon monoxide detectors and fire safety systems were present. LPA observed a chair lift is available on each floor by the stairwell. Chemicals, toxins, medication and sharps objects were locked and inaccessible to residents in care. 2 days of perishables and 7 days of nonperishable foods were observed for the residents. Hot water temperature through-out the facility was measured at 105- 108 degrees F. A review of (5) resident files was conducted and noted on the LIC 858. A review of (5) staff files was conducted and noted on the LIC 859. Comp III orientation was given to the administrator, David Wall. Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau. This report is reviewed and discussed with the co-administrator, Angelina Guzman as the administrator had to leave doing the inspection. A copy of the report is provided.the state’s words, verbatim · CDSS document, Oct 1, 2025

Type of visit: Office

Facility Type: RCFE Application Type: CHOW Capacity: 87 Census (if any clients in care): 69 COMP II Participants: licensee/administrator David Wall Interview Method: Telephone interview On 8/28/2025, applicant/administrator participated in COMP II. Identification of the applicant and administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, applicant and administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22. Signed LIC 809 with copy of photo ID have been obtained. During COMP II, CAB analyst confirmed Applicant/Administrator’s understanding of following areas: 1. Facility operation: License type, client/resident populations, and program 2. Admission Policies 3. Staffing requirements & Training 4. Restrictive/Prohibited Health Conditions 5. General provisions 6. Emergency Preparedness 7. Complaints & Reporting 8. Pre-licensing readinessthe state’s words, verbatim · CDSS document, Aug 28, 2025