385600427-3-9-2021-14-AS-KHOS-BYYQ5V-20210310105231

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600427
Report Date: 03/08/2021
Date Signed: 03/09/2021 03:38:11 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:	Claudia Morales		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Staff lost resident's dentures.

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 lost the resident's dentures, LPA Filouane conducted an investigation, interviewed the facility director, interviewed the resident's conservator, and requested documentation pertaining to the resident.

An interview with the FD revealed the resident had visited the hospital in July of 2020. The dentures had gone missing when the resident returned from the hospital, as reported by the FD. The facility denies losing the resident's dentures.

Unsubstantiated

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 an interview with the resident's conservator, LPA requested information on the hospital visit in July of 2020. The conservator confirmed the resident had gone to the hospital in July of 2020. When LPA Filouane asked about the dentures, the conservator stated they had requested information on the lost dentures from the facility, and the facility stated their staff had not lost the resident's dentures. The staff member who had taken the resident to the hospital no longer works at the facility, as confirmed by the conservator. The resident's dentures were never found after the resident returned to the facility from the hospital.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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)

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