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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:39:33 PM


Document Has Been Signed on 03/04/2024 12:39 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
SAN BRUNO RO, 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: 11DATE:
03/04/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Med-Tech Theresa MartinezTIME COMPLETED:
12:45 PM
NARRATIVE
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On 03/04/2024, Licensing Program Analyst (LPA) Jaime Vado, conducted an unannounced case management - deficiency visit. During a complaint visit made on this day LPA discovered a deficiency being cited today. LPA met with Med-Tech Theresa Martinez and explained the purpose of this visit.

Per staff interviews and observations made, there is only one care giver and one med-tech on duty today for the 11 residents in the building. This is a three level facility and on each floor there are at least one resident that requires double assistance. Interviews and observations found that additional staffing is required to provide the proper care and supervision needed for residents in care as well as their safety in the event of emergencies.

Deficiencies cited on following LIC809D.

Report is reviewed and discussed with Theresa Martinez.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
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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Document Has Been Signed on 03/04/2024 12:39 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
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: 03/04/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/05/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General - (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services. This regulation has not been met as evidenced by:
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The licensee shall provide a plan in writing to address and indicate how they well meet this regulation at all times. POC to be received by the date indcated.
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Based on observations made and interviews conducted, there currently is only 1 caregiver and 1 med-tech providing care and supervision to all 11 residents in care. There are at least 3 residents present that require double assistance present in the building today.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/04/2024
LIC809 (FAS) - (06/04)
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