385600427-3-9-2021-14-AS-KHOS-BYYQ5U-20210310105230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600427
Report Date: 03/08/2021
Date Signed: 03/09/2021 03:37:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/11/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210111121019

FACILITY NAME:	VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE		FACILITY NUMBER:	385600427
ADMINISTRATOR:	MORALES,CLAUDIA		FACILITY TYPE:	740
ADDRESS:	601 LAGUNA STREET		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	47	CENSUS: 23	DATE:	03/08/2021
		UNANNOUNCED	TIME BEGAN:	02:50 PM
MET WITH:	Claduia Moraels		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff has not observed resident's weight

INVESTIGATION FINDINGS:

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On 3/8/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up complaint inspection with Facility Director (FD) Claudia Morales, over the phone. Due to COVID-19 and health and safety concerns, LPA was not present in the facility. LPA spoke with the facility director, explained the purpose of the phone call, and then delivered the findings.

Concerning the allegation of staff having not observed the resident's weight, LPA Filouane conducted an investigation, interviewed the facility director, interviewed the resident's conservator, requested documentation pertaining to the resident, and cross-examined information from the resident's physician.

During the interview with the FD, LPA requested background information on the resident in question. The FD stated the resident had lost their dentures in July of 2020, and they had not been replaced since. During the period including June of 2020 to November of 2020, the facility staff had not documented the resident's weight. When the resident's weight was recorded in December of 2020, the facility documented a weight loss. Evidence collected details the exact months the facility staff had not observed the resident's weight.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

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-20210111121019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE	FACILITY NUMBER: 385600427
	VISIT DATE: 03/08/2021

NARRATIVE

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In a second interview with the resident's conservator on 3/4/21, LPA Filouane requested an update on the resident's situation. The conservator stated they had consulted with the resident's physician and confirmed the facility had not reported the change of food intake and weight loss of the resident over the course of six months to the resident's physician, dating to December of 2020.

The loss of dentures was a direct correlation of the resident's decrease in solid food in-take, which, over the course of six months, resulted in a loss of the resident's weight. The facility's inaction to replace the dentures of the resident and not reporting the lost dentures to the resident's conservator until December of 2020, is a violation of the resident's personal rights under Title 22, affording a safe and healthful environment.

According to Title 22 regulations, the Licensee shall ensure a safe and healthful environment. Evidence reveals the facility had not contacted the resident's conservator or physician regarding the lost dentures and change of food intake within reasonable time and displayed inaction for six months.

Based on LPA’s observations, record review, and interviews, which were conducted along with a file review, the preponderance of evidence has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6 & Chapter number 8) is being cited on the attached LIC 9099D.

Exit interview conducted with the Facility Director over the phone. The director will receive this LIC9099 report through email to sign and then will email the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 14-AS-20210111121019

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE	FACILITY NUMBER: 385600427
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/12/2021 Section Cited CCR 87468.1	1 2 3 4 5 6 7	Personal Rights of Residents in All Facilities (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.	1 2 3 4 5 6 7	The Licensee shall ensure staff observe residents as required under Title 22 regulations and report to the required parties when unusual changes occur. The Licensee shall also ensure residents are accorded safe, healthful and comfortable accomodations. A statement from the facility will be submitted to the Community Care Licensing Division adressing the plan of correction.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the Licensee failed to ensure that staff observed the weight loss of the resident and accord safe and healthful accomodations to assist in replacing the lost dentures.	8 9 10 11 12 13 14
	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.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2021

LIC9099 (FAS) - (06/04)

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