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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600427
Report Date: 08/24/2023
Date Signed: 08/24/2023 01:19:12 PM


Document Has Been Signed on 08/24/2023 01:19 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, THEFACILITY NUMBER:
385600427
ADMINISTRATOR:ELOIS THOMASFACILITY TYPE:
740
ADDRESS:601 LAGUNA STREETTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:47CENSUS: 4DATE:
08/24/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Resident Service Coordinator, Akelii StockstillTIME COMPLETED:
01:30 PM
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On August 24, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow- up on an incident that was reported by the state official on August 8, 2023 then 9 days later by the facility on August 17, 2023. LPA met with administrator, Simmon Bolivar and resident service coordinator and explained the purpose of today's visit.

On August 8, 2023, the Department was notified by the state official of an incident that happened at the facility that occurred on August 4, 2023. Staff #1(S1) heard commotion between 2 residents and rushed toward them and witnessed resident #1 (R1) was attacking resident #2 (R2) in the bathroom. S1 immediately intervened and yelled for assistance and staff #2 (S2) responded. Facility called 911 and R1 was taken to the acute hospital for further evaluation and R2 sustained some injuries but family did not want further medical interventions.

According to the state official, the facility refused to re-admit R1 back from the acute hospital.

The facility did not report this incident to the Department until August 17, 2023.

During today's visit, LPA interviewed resident service coordinator, requested for documents, observed R2 and obtained documents.

No deficiency cited today as further investigation is required.

This report is reviewed and discussed with administrator.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023
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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