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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 03/08/2024
Date Signed: 03/08/2024 02:46:27 PM


Document Has Been Signed on 03/08/2024 02:46 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: DATE:
03/08/2024
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Beau AyersTIME COMPLETED:
02:30 PM
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On 3/8/2024 San Bruno Regional Office conducted a non-compliance conference meeting with Regional Director of Operations, Beau Ayers, Director of Regulatory Compliance, Marlene Nelson & Corporate Support Nurse, Paulette Rubiales.

Present in the meeting are Regional Manager, Vivien Helbling, Licensing Program Managers, Jackie Jin & April Cowan, Licensing Program Analyst, Grace Donato, Ombudsman Richard Murphy.
 
During non-compliance meeting, the following violations were discussed, Personal Rights, Incidental Medical and Dental Care, Personnel Requirements, Employees assisting residents with self-administration of medication; training requirements, Basic services requirements, Personal Accommodations and Services, Resident Records, Personnel Records, Infection Control Requirements, Reporting Requirements, Emergency Plans, Emergency Disaster Plan.

During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years.  Licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/08/2024
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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