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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 01/11/2022
Date Signed: 01/11/2022 02:48:34 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THEFACILITY NUMBER:
385600428
ADMINISTRATOR:MORALES,CLAUDIAFACILITY TYPE:
740
ADDRESS:624 LAGUNA STTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:56CENSUS: 24DATE:
01/11/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator, Elois ThomasTIME COMPLETED:
03:00 PM
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On 1/11/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident that was verbally reported by the facility. LPA Han met with Administrator, Elois Thomas and explained the purpose of the visit.

On 12/23/2021, the facility reported to the desk duty officer at the Regional Office that a resident reported to the Resident Service Director who reported to the Administrator that he/she was purchasing clothes for a former staff and the resident was not reimbursed.

At the time of the reporting, the desk duty officer, requested the facility to submit a LIC 624 (Incident Report) for the situation, however, the Regional Office have yet received the LIC 624.

During today's visit, LPA interviewed the Administrator and the resident.

This incident requires further investigation.

This report is discussed and reviewed with the Administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2022
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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