385600427-3-8-2022-14-AS-JMOS-CCMT93-20220318143117

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600427
Report Date: 03/08/2022
Date Signed: 03/08/2022 12:17:58 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
03/02/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220302144521

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: 10	DATE:	03/08/2022
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Acting Administrator, Eloise Thomas		TIME COMPLETED:	12:25 PM

ALLEGATION(S):

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Facility did not issue refund to resident's authorized representative

INVESTIGATION FINDINGS:

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On 3/8/2022, Licensing Program Analyst (LPA) Han conducted an unannounced 10-day initial on-site complaint inspection. LPA met with the acting administrator, Elois Thomas. LPA explained the purpose of the visit and reviewed the allegation.

Regarding to Facility did not issue refund to resident's authorized representative- the reporting party stated that resident #1 (R1)'s authorized representative informed the facility on 2/4/22 that R1 would not be moved into the facility and the authorized representative ask for a refund of the preadmission fee in the amount of $3500. On 2/24/22, the authorized representative was told by the facility staff that the refund was processed on 2/7/22 and it should be received in 7-10 day; as of 3/4/22, the refund was not received by the authorized representative.

During the investigation, LPA Han interviewed the acting administrator who provided documents revealing that the refund in the amount of $3500 was processed on 2/7/2022, and the March statement revealing a zero balance, however, the facility was not able to provide any documents showing that the actual refund was credited to the authorized representative account.

Based on LPA’s observations, record review, and interview, the preponderance of evidence has been met, therefore the above allegation is found to be SUBSTANTIATED.

Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-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 is provided to the acting administrator.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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-20220302144521

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: 03/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/22/2022 Section Cited CCR 87507(g)(5)(E)(1)(a)	1 2 3 4 5 6 7	Admission Agreements ..(g) Admission agreements shall specify the following:(5) Refund conditions.(E) Preadmission fees shall be refunded according to the following conditions: 1.A 100 percent refund of a preadmission fee shall be provided to an applicant or the applicant’s representative if:a.The applicant decides not to enter the facility..	1 2 3 4 5 6 7	The Licensee will review this regulation and provide a written statement of acknowledgement to CCL after the review. The Licensee will provide proof to CCL that the refund was credited to the authorized representative's account by the plan of correction due date, 3/22/2022
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: the facility failed to provide document to show that the preadmission refund fee was credited to authorized representative's account which poses potential health and safety risks to resident in care.	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: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC9099 (FAS) - (06/04)

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