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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 09/22/2023
Date Signed: 09/22/2023 02:31:13 PM


Document Has Been Signed on 09/22/2023 02:31 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: 15DATE:
09/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Kayla Baker, Theresa MartinezTIME COMPLETED:
01:30 PM
NARRATIVE
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On 9/22/23, LPA Grace Donato conducted an unannounced visit to open an initial complaint investigation. During visit, LPA observed a violation therefore a case management - deficiencies visit was conducted. LPA met with Kayla Baker & Theresa Martinez and explained the purpose of the visit.

During the visit, LPA requested for documents to be available for review and copy. No one in the current staff in facility are able to access these documents. LPA asked for staff records, resident records and infection control plan.

A deficiency was cited per California Code of Regulations, Title 22. See LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report was reviewed and a copy of this report and the Appeal Rights are provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 09/22/2023 02:31 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-LAGUNA BUILDING, THE
FACILITY NUMBER: 385600428

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/23/2023
Section Cited
CCR
87412(f)

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87412 Personnel Records (f)All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying...This requirement was not met as evidenced by:

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Licensee to submit a plan of action on how to make these records readily available to Licensing. Licensee to submit plan to LPA by DUE DATE:09/23/23.
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Based on interview, there is no one avaibalbe currently in the facility to access personnel records which poses an immediate health, safety, or personal rights risk to persons in care.
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Type A
09/23/2023
Section Cited
CCR87506(d)

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87506 Resident Records (d) All resident records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying...This requirement was not met as evidenced by:

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Licensee to submit a plan of action on how to make these records readily available to Licensing. Licensee to submit plan to LPA by DUE DATE:09/23/23.
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Based on interview, there is no one avaibalbe currently in the facility to access resident records which poses an immediate health, safety, or personal rights risk to persons 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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 09/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/22/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2