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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 10/02/2023
Date Signed: 10/02/2023 07:54:38 PM


Document Has Been Signed on 10/02/2023 07:54 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:
10/02/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
01:12 PM
MET WITH:Resident Service Coordinator, Akelii StockstillTIME COMPLETED:
02:59 PM
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On 10/2/23, LPA Grace Donato conducted an unannounced visit to conduct a POC visit. LPA met with Med Tech, Theresa Martinez & Resident Service Coordinator, Akelii Stockstill followed after. LPA explained the purpose of the visit.

On 9/22/23, LPA conducted a case management - deficiencies report regarding the availability of both resident and staff records. LPA cited deficiencies and requested a POC be submitted the following day.

During today's visit, LPA hasn't received the POC. The deficiencies cited are 87412(f) & 87506(d).

Due to the above deficiencies not being corrected, a civil penalty is being assessed for violation of 87412(f) in the amount of $100 a day from 9/24/2023 through 10/2/2023 and will continue to accrue until corrected.

Another civil penalty is being assessed for violation of 87506(d) in the amount of $100 a day from 9/24/2023 through 10/2/2023 and will continue to accrue until corrected.

A total civil penalty of $1,800.00 is being assessed.

Report is reviewed and a copy of this report is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2023
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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