385600427-3-20-2023-14-AS-CSMH-CQ6VB3-20230322161651

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600427
Report Date: 03/20/2023
Date Signed: 03/20/2023 11:18:06 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
01/23/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083143

FACILITY NAME:	VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE		FACILITY NUMBER:	385600427
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	601 LAGUNA STREET		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	47	CENSUS: 7	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maintenance Director, Willie Webb		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Residents are left in soiled clothing for extended periods of time
Facility does not have sufficient amount of cleaning supplies

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 14-AS-20230123083143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE	FACILITY NUMBER: 385600427
	VISIT DATE: 03/20/2023

NARRATIVE

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Regarding the allegation that facility does not have sufficient amount of cleaning supplies, according to the reporting party, the facility is always low or out of stock on cleaning supplies that are used to clean up resident after they soil their diapers. During the investigation, LPA interviewed the administrator, facility staff and observed the supplies present at the facility. Interviewed staff acknowledged that they would use resident's personal incontinent supplies for other residents when the facility ran out of supplies especially wipes.

According to the administrator, the facility shares supplies with the assisted living facility, Village at Hayes-Laguna Building across the street. On 1/26/2023, LPA conducted a complaint visit to the facility and observed the main shared storage room and closet rooms located at the Laguna Building, however did not observe any incontinent supplies.

Based on interviews conducted, and information collected, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 9099D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Maintenance Director and a copy is provided with appeal rights.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
01/23/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083143

FACILITY NAME:	VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE		FACILITY NUMBER:	385600427
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	601 LAGUNA STREET		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	47	CENSUS: 7	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maintenance Director, Willie Webb		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff do not ensure special diets are followed for residents in care

INVESTIGATION FINDINGS:

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On March 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Maintenance Director, Willie Webb and explained the purpose of the visit.

Regarding the allegation that staff do not ensure special diets are followed for residents in care, according to the reporting party, the facility does not have a posted charts for specific residents who have special diets which causes an issue when agency staff come to the facility to work and serve meals to the residents. During the investigation, LPA interviewed the kitchen staff and toured the facility kitchen. The facility shares the same kitchen as the Assisted Living building, Village at Hayes- The Laguna Building located across the street, and the kitchen is located in the Laguna Building. During a complaint visit conducted to the facility, LPA observed a white board located in the kitchen with resident's names and their diet orders on it. In addition, according to the kitchen staff, the kitchen has a white board for all the residents with their diet orders. When a resident is admitted, the business office informs the kitchen of resident's diet and this information would be added to the white board for the kitchen staff to use during meal preparation. Furthermore, the white board is being updated accordingly and interviewed staff indicated that they are aware of resident's diet orders because when there is a change in a current resident's diet or a new admission, they would get that information from the supervisor or the medication technicians.

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

Report is reviewed with Maintenance Director and a copy is provided with appeals rights.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 7

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
01/23/2023 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083143

FACILITY NAME:	VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE		FACILITY NUMBER:	385600427
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	601 LAGUNA STREET		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	47	CENSUS:	DATE:	03/20/2023
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maintenance Director, Willie Webb		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff do not ensure that medications are dispensed as prescribed
Facility does not ensure that staff are properly trained in providing care to residents
Staff speaks inappropriately to residents in care
Facility allows staff to live in a vacant resident room
Facility failed to report incident to CCL

INVESTIGATION FINDINGS:

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On March 20, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegations. LPA met with Maintenance Director, Willie Webb and explained the purpose of the visit.

Regarding to the allegation of staff do not ensure that medications are dispensed as prescribed, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that resident's medications are getting skipped at different intervals especially during the morning med pass. During the investigation, LPA interviewed the administrator and family members.

According to the administrator, residents are receiving their medications according to the physician's order. According to 3 out of 3 family members, residents medications are being administered by staff on-time and staff made sure residents take their medication(s) before they leave their rooms.

Based on the investigation, this allegation is deemed to be unfounded.

Regarding to the allegation of facility does not ensure that staff are properly trained in providing care to residents. There is no additional information forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that director does not care about how the staff gets trained once they are hired. During the investigation, LPA interviewed the administrator, and reviewed staff training records. According to the administrator, she denied the allegation and stated newly hired staff received training on various topics from Relias, a healthcare training site. (CONT. to 9099C)

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 14-AS-20230123083143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE	FACILITY NUMBER: 385600427
	VISIT DATE: 03/20/2023

NARRATIVE

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Based on the Relias training certificate of completion provided by the facility, LPA observed staff completed various training such as Basic Nutrition and Food Safety, Dementia Care -Effects of Medications on Persons with Dementia, Abuse and Neglect in the Elder Care Setting- Dementia, Understanding Residents Rights, etc.

Based on the investigation, this allegation is deemed to be unfounded.

Regarding to allegation of staff speaks inappropriately to residents in care, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that the director just says to staff "these residents are just here to die" and one of the staff (name unknown) went off cussing and swearing at a resident. During the investigation, LPA interviewed the administrator and family members. According to the administrator, she denied this allegation and stated that no one has brought this matter to his/her attention. According to 3 out of 3 family members interviewed, all of them reported that they have not encountered being disrespected by any staff members and they have not witnessed any staff members spoke to other residents inappropriately. In addition, all of them reported that staff are polite.

Based on the investigation, this allegation is deemed to be unfounded.

Regarding the allegation that facility allows staff to live in a vacant resident room, according to the reporting party, a staff member is living in a vacant resident room but is not sure which room specific. During the investigation, LPA interviewed the administrator time and toured the facility. According to the administrator at the time, she acknowledged that there is a staff member who does utilize a vacant resident room on the first floor as a staff sleeping room, however that entire first floor of the facility, is vacant due to low census. LPA discussed this allegation with the administrator at the time and the current Interim administrator who both stated that since no resident's are residing on the first floor, resident's privacy and rights are not getting violated.

Based on the investigation, this allegation is deemed to be unfounded.
(CONT. to 9099C)

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 7

Control Number 14-AS-20230123083143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-GROVE BUILDING, THE	FACILITY NUMBER: 385600427
	VISIT DATE: 03/20/2023

NARRATIVE

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Regarding the allegation that the facility failed to report incident to CCL, according to the reporting party, on 1/19/2023, a resident left the facility unassisted and is not sure if the incident was reported to the Licensing Office. During the investigation, LPA interviewed the administrator at the time and she indicated that this resident is not a resident at this facility, however is a resident at their other community, Village at Hayes- Laguna Building which is an assisted living facility across the street from this facility.

Based on the above information, the Department has found that this allegation as well as the allegations above to be UNFOUNDED, meaning that these allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with the Maintenance Director and a copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 14-AS-20230123083143

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 03/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/21/2023 Section Cited HSC 1569.312	1 2 3 4 5 6 7	1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services: a) Care and supervision as defined in Section 1569.2. Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Licensee shall develop a plan of action in writing describing how the facility shall ensure residents are not being left in soiled beds for hours. Plan of correction to include plan to train staff.
	8 9 10 11 12 13 14	Based on interviews conducted, family members reported that it took a long time for staff to provide assistance with cleaning and changing them which posed an immediate health risk for residents in care.	8 9 10 11 12 13 14
Type A 03/21/2023 Section Cited CCR 87307(a)(3)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services..(a)Living accommodations(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. Violation of this regulation is evidenced by:	1 2 3 4 5 6 7	Licensee shall conduct rounds to ensure the facility has sufficient supplies to care for residents. Licensee shall develop a plan of action to ensure the facility has adequate incontinent supplies to care for resident at all times.
	8 9 10 11 12 13 14	Based on interviews conducted and observations made, the facility did not have incontinent supplies to care for residents which poses an immediate health risk for residents in care.	8 9 10 11 12 13 14

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal Charitra	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 03/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 7