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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
385600427
Report Date:
05/24/2023
Date Signed:
05/24/2023 12:50:37 PM
Document Has Been Signed on
05/24/2023 12:50 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
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
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:
6
DATE:
05/24/2023
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
11:15 AM
MET WITH:
Adiam Welday
TIME COMPLETED:
01:00 PM
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On this day LPA Vado conducted an unannounced case management visit in conjunction with a complaint visit made on this day.
According to her R1 was sent to the hospital on 05/11/2023 for a mental evaluation due to his/her behaviors being violent in nature and threatening to staff and residents. The resident had a wooden object in his/her possession threatening to use against staff if he/she was not let out of the facility. The police department was called to ensure the health and safety of residents and staff. R1 was found to have several objects in possession that are being brought in from an unknown source. R1 attends a day program 5 days a week and the belief is that it is originating from there or somewhere else outside of the facility. Adiam stated that LTCO of San Francisco is already involved as well as Institute of Aging (IOA) in developing a plan for him/her to re enter the facility due to behaviors. R1 stayed at the hospital until 05/23/2023 for that span of time due to COVID status and clearance. The resident is now back at the facility with a safety plan in place that was developed with IOA and LTCO suggestions were taken into consideration.
Report is reviewed with the administrator.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
05/24/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
05/24/2023
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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