385601188-5-8-2026-14-AS-BCHN-DU9LMM-20260520085254

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601188
Report Date: 05/08/2026
Date Signed: 05/08/2026 11:54:39 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2026 and conducted by Evaluator Yi Sam Jian

COMPLAINT CONTROL NUMBER: 14-AS-20260127150741

FACILITY NAME:	BUENA VISTA MANOR HOUSE		FACILITY NUMBER:	385601188
ADMINISTRATOR:	WALL, DAVID R.		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA AVENUE EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS: 75	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Angie Guzman		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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8
9

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

INVESTIGATION FINDINGS:

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5
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9
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13

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

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/27/2026 and conducted by Evaluator Yi Sam Jian

COMPLAINT CONTROL NUMBER: 14-AS-20260127150741

FACILITY NAME:	BUENA VISTA MANOR HOUSE		FACILITY NUMBER:	385601188
ADMINISTRATOR:	WALL, DAVID R.		FACILITY TYPE:	740
ADDRESS:	399 BUENA VISTA AVENUE EAST		TELEPHONE:	(415) 863-1721
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94117
CAPACITY:	87	CENSUS: 75	DATE:	05/08/2026
		UNANNOUNCED	TIME BEGAN:	09:37 AM
MET WITH:	Angie Guzman		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Staff pushed resident
-Staff hit resident
-Staff yelled at resident

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

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 pushed a resident, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Regarding the allegation that staff hit a resident, the Department conducted interviews and reviewed records. There was insufficient corroborating documentation and witness statements to determine whether the alleged incident occurred. Regarding the allegation that staff yelled at a resident, 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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20260127150741

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: BUENA VISTA MANOR HOUSE	FACILITY NUMBER: 385601188
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/08/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/18/2026 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	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 manner	1 2 3 4 5 6 7	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.
Type B 05/18/2026 Section Cited CCR 87468.1(a)(3)	1 2 3 4 5 6 7	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.	1 2 3 4 5 6 7	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.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 05/08/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2026

LIC9099 (FAS) - (06/04)

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