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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600427
Report Date: 09/19/2024
Date Signed: 09/19/2024 10:53:36 AM


Document Has Been Signed on 09/19/2024 10:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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



FACILITY NAME:VILLAGE AT HAYES VALLEY-GROVE BUILDING, THEFACILITY NUMBER:
385600427
ADMINISTRATOR:ELOIS THOMASFACILITY TYPE:
740
ADDRESS:601 LAGUNA STREETTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:47CENSUS: 0DATE:
09/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:TIME COMPLETED:
11:00 AM
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On September 19, 2024, Licensing Program Analyst (LPA) John Calandra arrived at the facility at 10:19 AM to conduct a facility closure case management inspection to verify the facility closure. The visit was in response to a letter sent by the licensee dated 09/18/2024, notifying CCLD of facility closure. The letter stated the facility had been officially closed as of July 24, 2024 and all residents relocated as of June 22, 2024.

LPA Calandra did not observe evidence of care and supervision in the facility. It appears that all clients who require care and supervision have been relocated as stated in the letter. LPA Calandra rang the facility call button/doorbell and knocked on the door twice and there was no response. The facility was observed to be empty with minimal furnishings that could be seen from windows. A forfeiture letter will be sent to licensee and the facility number 385600427 shall be closed.

An exit interview was not conducted as there was no facility representative available to meet with. A copy of this report will be mailed to the Licensee.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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