385600428-8-8-2023-14-AS-CSMH-CUKSN7-20230810140103

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 08/08/2023
Date Signed: 08/08/2023 01:32:23 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
05/17/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230517111652

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: 16	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Resident Care Coordinator, Akelii Stockstill		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility staff incorrectly billed resident.
Facility does not provide activities for residents.

INVESTIGATION FINDINGS:

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On August 8, 2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230517111652. LPA Han met with Resident Care Coordinator, Akelii Stockstill and Business Office Manager, Amber Wright and explained the purpose of the visit.

As part of the investigation, LPA interviewed resident, facility staff and reviewed documents.

Regarding to allegation of facility staff incorrectly billed resident, the reporting party/responsible party of resident #1 (R1) stated that the facility switched the billing system from sending out statements to an on-line billing system and this change was not communicated to the reporting party/responsible party which resulted in delay in monthly payments and late fees were incurred.

LPA interviewed Business Office Manager who acknowledged that monthly statements were not mailed to residents and their responsible parties and late fees were automatic generated by the billing system. However, corporate office was aware of the situation and late fees have been waived.

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

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

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 5

Control Number 14-AS-20230517111652

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: 08/08/2023

NARRATIVE

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Regarding to allegation of facility does not provide activities for residents- the reporting party /responsible party stated that facility has no activity person and R1 has been watching TV all day.

LPA interviewed Resident Care Coordinator/staffing coordinator who stated that there was no Activity staff from May 2023 until a couple of months ago when the facility hired a new activity staff. During that period, other staff members such as the front desk staff, the caregivers, etc. assisted with resident activities whenever they had time.

LPA interviewed R1 who stated that facility did not provide any activities for many months until they hired the activity staff recently who has been conducting activities for the residents.

After the investigation, this allegation has been substantiated.

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 California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with resident care coordinator and business office manager.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 5

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
05/17/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230517111652

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: 16	DATE:	08/08/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Resident Care Coordinator, Akelii Stockstill		TIME COMPLETED:	01:40 PM

ALLEGATION(S):

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Facility staff leave resident in urine.

INVESTIGATION FINDINGS:

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On August 8, 2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230517111652. LPA Han met with Resident Care Coordinator, Akelii Stockstill and Business Office Manager, Amber Wright and explained the purpose of the visit.

As part of the investigation, LPA interviewed resident involved and reviewed documents.

Regarding to allegation of facility staff leave resident in urine- the reporting party/responsible party stated that on weekends, resident #1 (R1) sat in urine for hours until a caregiver can get to him/her.

LPA interviewed R1 who stated that he/she has never sat in urine as he/she is independent with activities of daily living, and ambulation. Therefore, he/she is able to go to the bathroom independently.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 14-AS-20230517111652

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: 08/08/2023

NARRATIVE

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According to R1's service and needs plan, R1 is able to ambulate independently with a walker and standby assist with shower.

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

Based on the above information, 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.

Report is reviewed with resident care coordinator and business office manager.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 14-AS-20230517111652

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: 08/08/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/16/2023 Section Cited CCR 87468(a)(8)	1 2 3 4 5 6 7	7468.1 Personal Rights of Residents in All Facilities..(8) To have their representatives regularly informed by the licensee....	1 2 3 4 5 6 7	The administrator/licensee will provide proof that late fees were waived for residents as indicated by the facility director. This will be submitted to CCL by 8/16/2023.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility failed to provide monthly statements to R1's responsible party which resulted delay in payments and R1 incurred late fees which posed a potential health risk to resident in care.	8 9 10 11 12 13 14
Type B 08/16/2023 Section Cited CCR 87219(f)	1 2 3 4 5 6 7	87219 Planned Activities..(f) In facilities licensed for fifty (50) persons or more, one staff member shall have full-time responsibility to organize, conduct and evaluate planned activities,..	1 2 3 4 5 6 7	The administrator/licensee will review the regulation and provide a signed statement of understanding after the review. In addition, the administrator/licensee will develop a plan to ensure compliance.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by facility did not have full time activity staff member to organize, conduct and evaluate planned activities until recently which posed an immediate health risks to resident in care.	8 9 10 11 12 13 14	A copy of the plan and the statement shall be submitted to CCL by 8/16/2023.

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: 08/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2023

LIC9099 (FAS) - (06/04)

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