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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 07:55:56 PM


Document Has Been Signed on 10/02/2023 07:55 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:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Resident Service Coordinator, Akelii StockstillTIME COMPLETED:
04:08 PM
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On 10/2/23, LPA Grace Donato conducted an unannounced visit to conduct a case management visit. LPA met with Resident Service Coordinator, Akelii Stockstill. LPA explained the purpose of the visit.

It was reported to Licensing that facility has not been reporting incidents, are having medication errors and doesn't have a designated administrator in the building. LPA was able to obtain some resident & staff files. There is no administrator in the building but will be having one in two days. LPA was able to interview some staff members.

LPA was able to contact Beau Ayers, Regional Vice President of Operations. LPA sent an email requesting for some records to be sent to LPA.

No deficiencies cited today. 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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