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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 08/24/2023
Date Signed: 08/24/2023 01:16:38 PM


Document Has Been Signed on 08/24/2023 01:16 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-LAGUNA BUILDING, THEFACILITY NUMBER:
385600428
ADMINISTRATOR:ELOIS THOMASFACILITY TYPE:
740
ADDRESS:624 LAGUNA STTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:56CENSUS: 13DATE:
08/24/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Administrator, Simmon BolivarTIME COMPLETED:
01:30 PM
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On August 24, 2023 Licensing Program Analysts (LPA) Murial Han conducted an unannounced plan of correction visit. LPA met with administrator and explained the purpose of the visit.

On August 8, 2023 facility received 2 type B citations in reference to complaint #14-AS-20230517111652 with a plan of correction due date of August 16, 2023.

As of August 24, 2023, the Department has yet received the plan of correction documents and facility was not able to provide it during today's visit.

Due to deficiencies not being corrected, a civil penalty is being assessed in the amount of $100 a day from 8/17/2023 through 8/24/2023 and will continue to accrue until corrected for both citations.

A total civil penalty of $1600 is being assessed today.
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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