385600428-3-8-2023-14-AS-KHOS-CQCN5G-20230328100932

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:52:56 PM

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 Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083310

FACILITY NAME:	VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE		FACILITY NUMBER:	385600428
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	624 LAGUNA ST		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	56	CENSUS: 19	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Executive Director, Amanda North		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Residents are left in soiled clothing for extended periods of time

INVESTIGATION FINDINGS:

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On 3/8/2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230123083310. LPA Han met with the interim executive director and explained the purpose of the visit.

Regarding to allegation of residents are left in soiled clothing for extended periods of time, there is no additional information forthcoming from the reporting party, however, during the initial reporting, the reporting party stated that residents are left in soiled beds for hours before being changed.

As part of the investigation, LPA interviewed the administrator, residents, family members and staff members.

The administrator denied the allegation, however, based on residents and family members interviews, 3 out of 6 residents and 2 out of 2 family members stated that there were days especially at night and on weekends it took a long time for staff to answer the call pendent to provide assistance with care and sometimes the family members had to go and find staff because there was no one answering their call.

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)

Page: 1 of 8

Control Number 14-AS-20230123083310

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-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 03/08/2023

NARRATIVE

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LPA interviewed 3 staff members and all of them reported that facility has staffing challenges especially at night on the weekends.

The facility received a citation on 1/18/2023 for insufficient staff to provide care.

After the investigation, this allegation deemed to be substantiated as the facility failed to provide on-going assistance to residents with their activities of daily living.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the Health and Safety Code on a LIC9099D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the interim Executive Director.

A copy of this report and Appeal Rights were provided.

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)

Page: 2 of 8

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 Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083310

FACILITY NAME:	VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE		FACILITY NUMBER:	385600428
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	624 LAGUNA ST		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	56	CENSUS: 19	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Executive Director, Amanda North		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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

INVESTIGATION FINDINGS:

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Unsubstantiated

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)

Page: 3 of 8

Control Number 14-AS-20230123083310

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-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 03/08/2023

NARRATIVE

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According to the kitchen staff who explained that the kitchen has a white board that is color coordinated for all the residents with their diet orders. When a resident is admit, 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. In addition, the white board is being updated accordingly.

During the initial 10-day complaint visit, LPA observed this white board in the kitchen with resident's name, and their diet orders on it. In addition, if a resident has a special diet order such as diabetic, mechanical soft, etc., this information is being communicated by a colored marker on the white board.

LPA interviewed 6 residents and all of them stated staff is aware of their diet and they have no concerns regarding that.

LPA interviewed 3 staff members and all of them reported that they were aware of resident's diet orders and 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. In addition, if they have any questions, they would ask the medication technicians.

Based on observation, record review and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated.

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.

This report is reviewed and discussed with the interim executive director.

A copy is provided.

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)

Page: 4 of 8

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 Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230123083310

FACILITY NAME:	VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE		FACILITY NUMBER:	385600428
ADMINISTRATOR:	ELOIS THOMAS		FACILITY TYPE:	740
ADDRESS:	624 LAGUNA ST		TELEPHONE:	(415) 318-8670
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94102
CAPACITY:	56	CENSUS: 19	DATE:	03/08/2023
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Interim Executive Director, Amanda North		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Staff speaks inappropriately to residents in care
Staff do not ensure that medications are dispensed as prescribed
Facility does not ensure that staff are properly trained in providing care to residents

INVESTIGATION FINDINGS:

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On 3/8/2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230123083310. LPA Han met with the interim executive director and explained the purpose of the visit.

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.

As part of the investigation, LPA interviewed facility administrator, residents, and family members.

The administrator denied this allegation and stated that no one has brought this matter to his/her attention.

Unfounded

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)

Page: 5 of 8

Control Number 14-AS-20230123083310

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-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 03/08/2023

NARRATIVE

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LPA interviewed 6 residents and 2 family members and all of them reported that they have not encountered being disrespect 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 respectful.

After the investigation, this allegation is deemed to be unfounded.

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.

As part of the investigation, LPA interviewed the administrator, residents and family members.

According to the administrator, residents are receiving their medications according to the physician's order.

According to 6 residents and 2 family members, their medications are being administered by staff on-time and staff made sure they take their medication(s) before they leave their rooms.

After 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.

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)

Page: 6 of 8

Control Number 14-AS-20230123083310

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-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 03/08/2023

NARRATIVE

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As part of the investigation, LPA interview administrator, residents, and family members and reviewed facility training records.

The administrator denied the allegation and stated newly hired staff received training on varies topics from Relias, a healthcare training site.

Based on the Relias training certificate of completion provided by the facility, LPA observed staff completed varies 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.

LPA interviewed 6 residents and 2 family members regarding to staff training and all of them reported that they did not have any concerns to staff training; 1 family member stated that new staff could benefit from additional training. However, all of them reported that there is a concern with facility staffing shortage which is already addressed on a LIC9099D.

After the investigation, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with the interim executive director.

A copy is provided.

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)

Page: 7 of 8

Control Number 14-AS-20230123083310

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-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/09/2023 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.	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	This requirement is not met as evidenced by residents and 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	The facility will provide a copy of such plan to CCL by 3/9/2023
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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)

Page: 8 of 8