385600428-12-29-2023-14-AS-KHOS-CZQJDZ-20240122055819

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 12/29/2023
Date Signed: 12/29/2023 10:42:47 AM

Unsubstantiated

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
05/04/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230504080410

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:	12/29/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Administrator Adiam Welday		TIME COMPLETED:	10:45 PM

ALLEGATION(S):

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- Illegal Eviction
- Resident is being retaliated by the facility
- Facility not meeting the need of the resident in a timely manner

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings in regards to the allegations referenced above. LPA met with Adiam Welday and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, reviewed pertinent documents related to R1and their fees, and made facility observations. It is discovered that there was an agreement made with the facility's previous administrator in 2020 in a verbal format agreement with the family for a lifetime set monthly fee. The new administrator was not aware of such agreement. It was later discovered in email form from the previous administrator in 2020 informing the previous community relations director of the lifetime fee but did not make this lifetime fee official with the facility's corporate office. After this discovery the eviction letter was recisinded as it was issued for non-payment of fees that went above the lieftime set fee. The facility was not aware of the lifetime fee agreed upon in 2020. The lifetime fee is being honored by the facility after the new information. LPA could not prove or disprove retaltiation against R1 or R1's needs not being met in a timely manner, as staffing is in place and for opertaional purposes staff are diverted and have to assist other residents thourgh out the building. R1 does not have one on one care or a private caregiver. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023

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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