385600428-12-11-2023-14-AS-KHOS-CZHNSY-20240115094355

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 12/11/2023
Date Signed: 12/11/2023 04:14:42 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
09/15/2023 and conducted by Evaluator Grace Donato

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230915123335

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: 11	DATE:	12/11/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Adiam Welday		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff training is not current
Facility did not report COVID outbreak
Facility did not follow infection control plan
Facility did not send eviction letter to CCL

INVESTIGATION FINDINGS:

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On 12/11/23, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced visit to deliver findings for the above allegations. LPA met with Executive Director Adiam Welday and explained the purpose of today's visit.

Regarding the allegation of staff training is not current being current, the reporting party (RP) mentioned that there has been no training happening on site for a long time, and that the last training was from the first few months of 2022.

Based on record reviews, there were trainings conducted in 2023 for the months of April, May & June. However, first aid training was not current. The facility corrected this certification on December 08, 2023.

Regarding the allegation of facility did not report COVID outbreak, RP stated that on 9/1/23, there were several staff and residents who tested positive for the COVID-19 virus.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230915123335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 12/11/2023

NARRATIVE

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Based on record reviews, there was only one incident report submitted to CCL. There was no incident report received regarding staff and additional residents being infected. LPA also interviewed three staff and it was mentioned that there were more residents that got infected. On staff (S1) stated that there were reports made but that the staff who should’ve submitted it got sick too. Another staff member (S2) mentioned that when incidents happen, they only report them to upper management, and they are not aware of what happens after this.

Regarding the allegation of facility did not follow the infection control plan, RP stated that facility has no emergency PPE supply.

Based on interviews, according to RP, they asked around if there were any emergency PPEs available. There was none, even masks were not available. RP was also told that it had already been brought up to a higher level, but nothing was done. S1 confirmed that there was no emergency PPE supply in the facility. Past Executive Directors have known that there were no PPEs and were instructed to get kits but weren’t able to.

Regarding the allegation of facility did not send eviction letter to CCL, RP stated that there might be a concern for probable illegal eviction.

Based on record reviews, RP provided a document of a letter of eviction to a resident. LPA reviewed and it showed all the elements required in an eviction letter. This letter was not submitted to CCL within five days.

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. A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230915123335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 12/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/12/2023 Section Cited CCR 87411(c)(1)	1 2 3 4 5 6 7	Personnel Requirements – General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training... (1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.	1 2 3 4 5 6 7	Facility corrected by updating training certification.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on record reviews facility not having current first aid training for staff which poses an immediate health risk for residents in care.	8 9 10 11 12 13 14
Type A 12/12/2023 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (1)A written report shall be submitted to the licensing agency...(D) Any incident which threatens the welfare, safety or health of any resident...	1 2 3 4 5 6 7	Facility to submit a plan on how to address reporting requirements to be submitted to LPA on due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on record reviews and interviews there was no incident report received regarding staff and additional residents being infected which poses an immediate health risk for residents in care.	8 9 10 11 12 13 14

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: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230915123335

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 12/11/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/12/2023 Section Cited CCR 87470(b)(4)	1 2 3 4 5 6 7	Infection Control Requirements (b)In addition to subsection (a), when one or more residents in the facility are diagnosed with a contagious disease, the following shall apply: (2) All staff and volunteers providing direct care to a resident who has a contagious disease shall wear appropriate Personal Protective Equipment (PPE)...	1 2 3 4 5 6 7	Facility to submit a plan on how it will address the lack of PPE in the facility. Facility to also submit photo as proof of PPE supply. Facility to submit to LPA on due date
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on interviews there was no emergency PPE supply in the facility which poses an immediate health risk for residents in care.	8 9 10 11 12 13 14
Type B 12/18/2023 Section Cited CCR 87224(f)	1 2 3 4 5 6 7	Eviction Procedures (f) A written report of any eviction shall be sent to the licensing agency within five (5) days.	1 2 3 4 5 6 7	Facility to submit a plan on how to address the process of eviction. Facility to submit to LPA on due date.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on record reviews and interviews there was no eviction letter submitted for CCL for review, which poses a potential health risk to resident in care.	8 9 10 11 12 13 14

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: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace Donato	TELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC9099 (FAS) - (06/04)

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