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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600427
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:01:40 PM


Document Has Been Signed on 09/20/2023 03:01 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: 0DATE:
09/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Resident Service Coordinator, Akelii StockstillTIME COMPLETED:
01:05 PM
NARRATIVE
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On September 20, 2023, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to deliver the findings in reference to a case management visit that was conducted on August 24, 2023. LPA met with resident service coordinator and explained the purpose of today's visit.

On August 24, 2023, LPA Han conducted an unannounced visit to follow up on an incident that was reported by the facility that happened on August 4, 2023- Staff #1 (S1) witnessed resident #1 (R1) was attacking resident #2 (R2) in the bathroom. S1 immediately called for assistance and intervened to ensure resident's safety.

Subsequently, 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 a State Official and R1's case management agency, when R1 was ready to return to the facility after the hospital stay, the facility refused to take R1 back.

According to facility director, facility received a call from R1's case manager informing the facility that R1 was ready to return and facility director informed the case manager that the facility would not be re-admitting R1 as R1 was endangering to self and other. In addition, facility director stated that a reappraisal of R1 was not completed.

Based on interviews and record reviews, deficiencies are cited for Eviction Procedures as facility refused to re- admit R1 without a reappraisal and Reporting Requirement as the incident happened on August 4, 2023 and it was reported to CCL on August 17, 2023.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Resident Service Coordinator. A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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Document Has Been Signed on 09/20/2023 03:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 09/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/21/2023
Section Cited
CCR
87224(a)(4)

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87224 Eviction Procedures(a) The licensee may evict a resident..Thirty (30) days written notice to the resident is required..(4) If, after admission, it is determined that the resident has a need not previously identified and a reappraisal has been conducted..This requirement was not met as evidenced by:
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The licensee will review the regulation and develop a plan to ensure compliance.
The licensee will submit a copy of the plan to CCL by the plan of correction due date of 9/21/2023.
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This requirement is not met as evidenced by facility failed to follow Eviction Procedures when R1 was ready to go back to the facility after R1's hospital stay which posed an immediate health risks to residents in care.
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Type B
09/27/2023
Section Cited
CCR87211(a)(1)

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87211 Reporting Requirements..a)Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:1)A written report shall be submitted to the licensing
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The administrator/licensee will review the regulation and develop a plan to ensure compliance.
The administrator /licensee will submit a copy of the plan to CCL by the plan of correction due date of 9/27/2023.
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agency ..within seven days of the occurrence of any of the events..This requirement is not met as evidenced by the incident of resident to resident altercation happened on 8/4/2023 and reported to CCL on 8/17/2023 which posed a potential health risk to residents in care.
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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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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