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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600427
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:48:11 PM


Document Has Been Signed on 03/01/2022 02:48 PM - It Cannot Be Edited

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: 10DATE:
03/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Acting Administrator, Elois ThomasTIME COMPLETED:
03:00 PM
NARRATIVE
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On 3/1/2022, Licensing Program Analyst (LPA), Murial Han conducted an announced visit to deliver a deficiency for Administrator- Qualifications and Duties.

On 10/29/2021, the Department was notified that the Administrator, Caludia Morales, had left the facility and was no longer employed by the licensee. The notification was made by Elois Thomas, who also stated that she (Ms. Thomas) would be the interim Administrator. Ms. Thomas also indicated that she was waiting to take the Administrator Certification Examination on 11/5/2021 and be appointed as administrator. Therefore, LPA Han provided a list of documents required to report to the Department that in the absence of the administrator, the licensee had designated an interim substitute with the required qualifications required under Section 87405 (a). This Section (Administrator - Qualifications and Duties), species that all facilities shall have a qualified and currently certified administrator, and when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. As indicated, the licensee needed to provide a board resolution appointing the staff as the interim Administrator, a copy of the LIC 308 (Designation of Facility Responsibility), and a copy of the LIC 309 (Administrative Organization). The documents were required within 7-days as part of reporting requirements to inform the Department that an interim administrator had been named until a fully qualified administrator could be hired. Under Section 87405 Administrator - Qualifications and Duties – subsection (a) species that all facilities shall have a qualified and currently certified administrator, and when the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. Nevertheless, those required documents were not received by CCLD by the due date; therefore, the licensee failed to demonstrate that there was the required coverage in the absence of an administrator as required under this section.

Acting Administrator is refusing to sign.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/01/2022
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On 11/27/2021, the Department was notified that the candidate (“interim”) administrator had passed the Administrator Certification Examination; subsequently, on 11/29/2021, LPA Han emailed to the facility a list of the required documents necessary to report and update the administrator’s requirements for the facility. Those documents included a board resolution appointing the new Administrator, a copy of current Administrator’s Certificate (or proof that certificate was pending to be issued), a copy of the LIC 308 (Designation of Facility Responsibility), LIC501 Personal Report, LIC500 Personnel report, LIC503 Health Screening report/TB test, LIC508 Criminal Record, and a copy of the LIC 309 (Administrative Organization). Section 87211 Reporting Requirements, subsection (g) requires the licensee to notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. However, the licensee failed to respond and provide the corresponding forms and documents.

On 2/1/2022 the licensee wanted to confirm that the change of administrator had occurred. LPA Han notified the licensee that the facility failed to submit the required documentation in violation of Section 87211 Reporting Requirements. Then, the licensee submitted partial documentation. The facility failed to provide verification that the named staff had a current administrator’s certification and failed to submit a completed and updated LIC 610E (Emergency Disaster Plan for Residential Care Facilities for the Elderly). The LIC610E is a form that is posted at the facility, among other reasons to clearly and publicly designate responsibilities in case of emergency. Instead, on 2/24/2022, the licensee submitted a LIC610E referring to the emergency and evacuation plan contained within the plan of operations, which does not requires posting.

Based on the above information, the licensee has failed to provide evidence to the Department that there has been a qualified designated administrator’s substitute as specified under Section 87405 (a); furthermore, the licensee has not had a qualified certified administrator as required under the same Section since 10/29/2021. Moreover, the facility has failed to report a change of administrator as required under Section 87211 Reporting Requirements.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC809-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with the acting administrator, and Appeal Rights provided.

A copy of this report was provided to the acting administrator.

Acting Administrator is refusing to sign.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 03/01/2022 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited

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Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department.(1) A written report shall be submitted to the licensing agency.. within seven days (D) Any incident which threatens the welfare...
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This requirement is not met as evidenced by: the facility failed to provide the documents requested by the Department within 7-days for appointing an interim Administrator which poses potential health and safety risks to resident in care.
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A statement from the facility will be submitted to the Community Care Licensing Division addressing the facility's plan of correction. The plan of correction is due by 3/15/2022.
Acting administrator refuses to sign.
Type B
03/15/2022
Section Cited

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Reporting Requirements
(g) The licensee shall notify the Department, in writing, within thirty (30) days of the hiring of a new administrator. This requirement is not met as evidenced by: on 11/27/21, the Department was notified that the interim administrator had passed the Administrator Certification
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Examination; subsequent, on 11/29/21, LPA emailed to the facility the list of the required documents necessary to report and update the administrator's requirements for the facility. As of today 3/2/2022, the Department has not provided the completed LIC610E forms which posed potential health and safety risks to resident in care.
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The facility will submit a copy of the LIC 610E clearly addressing the Emergency Disaster Plan and referring to the emergency and evacuation plan. This plan of correction is due by 3/15/2022.

Acting Administrator refuses to sign.
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 MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 03/01/2022 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/07/2022
Section Cited

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Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator...When the administrator is not in the facility, there shall be coverage by a designated substitute who
shall have qualifications adequate to be responsible and
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accountable for management and administration of the facility as specified in this section. This requirement has not be met as evidence by: on 10/29/2021, the Department was notified that the administrator had left and was no longer employed by the facility. As of today, the facility failed to provide evidence to the Department that the facility has a certified administrator. The lack of administrator poses an immediate health and safety risks to resident in care.
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Acting Administrator refuses to sign.

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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 MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4