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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601188
Report Date: 05/08/2026
Date Signed: 05/08/2026 11:58:11 AM

Unsubstantiated


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
02/05/2026 and conducted by Evaluator Yi Sam Jian
COMPLAINT CONTROL NUMBER: 14-AS-20260205155224
FACILITY NAME:BUENA VISTA MANOR HOUSEFACILITY NUMBER:
385601188
ADMINISTRATOR:WALL, DAVID R.FACILITY TYPE:
740
ADDRESS:399 BUENA VISTA AVENUE EASTTELEPHONE:
(415) 863-1721
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94117
CAPACITY:87CENSUS: 75DATE:
05/08/2026
UNANNOUNCEDTIME BEGAN:
11:09 AM
MET WITH:Angie GuzmanTIME COMPLETED:
12:20 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
-Resident was not accorded dignity in their personal relationship with staff member.
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 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.
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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