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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600427
Report Date: 09/30/2021
Date Signed: 09/30/2021 04:56:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
385600427
ADMINISTRATOR:MORALES,CLAUDIAFACILITY TYPE:
740
ADDRESS:601 LAGUNA STREETTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:47CENSUS: 13DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Jamie GilesTIME COMPLETED:
05:00 PM
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On 09/30/2021, Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra toured facility's building and grounds to conduct an annual infection control inspection visit. LPA met with administrator Jamie Giles and explained purpose of today's visit.

There is no accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available. First-aid kit is complete. Disaster and Mass Casualty Plan is current and will be sent to regional office for filing. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. LPA observed entry questions and procedures as well as masking requirements. All are in place. Signs are present regarding masking, distancing. Disaster drill log is current. LPA reviewed mitigation plan with administrator updates will be forwarded for approval. LPA advised facility to add more masking signs as resident reminders. Administrator certificate is current.

The following updated forms are requested to be submitted to CCLD by 10/07/2021:

• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• Docs to update administrator
• Copy of disaster drill log

Report reviewed with licensee/administrator. No citations issued.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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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