385600427-3-8-2023-14-AS-KHOS-CQCLTM-20230328090235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600427
Report Date: 03/08/2023
Date Signed: 03/08/2023 11:58:32 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
02/27/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230227100353

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: 8	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim of Executive Director, Amanda North		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff failed to notify authorized representative of resident's fall resulting in hospitalization

INVESTIGATION FINDINGS:

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On March 8, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced 10-day complaint visit. LPA met with the Interim of Executive Director, Amanda North and explained the purpose of the visit.

Regarding to allegation of- staff failed to notify authorized representative of resident's fall resulting in hospitalization, the reporting party stated that resident #1 (R1) was transferred to the hospital in December 2022 due to a fall and the authorized responsible party was not notified by the facility when the incident occurred instead the responsible party was notified by the hospital on the following day.

According to the Interim Executive Director, when a resident has a change of condition, the facility completes an Unusual Incident/Injury Report (LIC624) that indicates who were notified including but not limiting to the responsible party, Licensing, Ombudsman, etc. and facility staff completes additional documentation of the change of condition.

Based on the LIC 624 for R1's incident, the only individual that was notified of the incident was the responsible party, however, based on another internal documentation, it indicated that the responsible party was not notified and the responsible party communicated in writing to the former Executive Director that he/she was not notified of the incident and he/she was seeking for an explanation.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

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-20230227100353

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: 03/08/2023

NARRATIVE

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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 interim executive director, and Appeal Rights provided.

A copy of this report is provided to the interim executive director.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230227100353

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: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/15/2023 Section Cited CCR 87468.1(a)(8)	1 2 3 4 5 6 7	87468.1Personal Rights of Residents in All Facilities(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(8)To have their representatives regularly informed by the licensee of activities related to care or services...	1 2 3 4 5 6 7	Licensee shall develop a plan of action in writing describing how the facility shall ensure all individuals including but limiting to the responsible party is notified when a resident sustained a change of condition.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by R1 was transferred to the hospital in December 2022 due to a fall and the responsible party was not notified which posed a potential health risk to residents in care.	8 9 10 11 12 13 14	Plan of correction to include plan to train staff. Licensee will submit a copy of such plan and a copy of staff in-service sign-in record to CC by 3/15/2023.
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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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC9099 (FAS) - (06/04)

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