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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:52:55 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
12/26/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231226104337
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: 10DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Coordinator, Maryanne RodriguezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility staff are not providing resident's with an up to date and readily available emergency disaster plan
INVESTIGATION FINDINGS:
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On March 5, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20231226104337. LPA Han met with resident care coordinator and explained the purpose of today's visit.

Regarding to allegation of facility staff are not providing resident's with an up-to-date and readily available emergency disaster plan, there is no additional information forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that safety training's are not conducted at the facility and the emergency disaster plan is outdated with incorrect leadership listed.

As part of the investigation, LPA interviewed the administrator, facility staff and reviewed documents.

LPA interviewed the administrator who was hired in Oct, 2023 and provided a copy of the emergency disaster plan that was updated in January 2024 but was not able to provide a copy of the emergency disaster plan prior to that. In addition, there was no documentation to proof that emergency disaster training was completed for facility staff in 2023.

Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
12/26/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231226104337

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: 10DATE:
03/05/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Coordinator, Maryanne RodriguezTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Administrator is not present a sufficient number of hours to adequately
Licensee does not ensure facility is adequately staffed to meet residents' medication needs
Facility staff are not properly dispensing medication as prescribed.
INVESTIGATION FINDINGS:
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On March 5, 2024, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20231226104337. LPA Han met with resident care coordinator and explained the purpose of today's visit.

Regarding to allegation of - Administrator is not present a sufficient number of hours to adequately managed facility, there is no additional details forthcoming from the reporting party. However, during the initial reporting, the reporting party stated that the administrator checks the facility once a week and the administrator is not available in a timely manner for calls during emergencies.

As part of the investigation, LPA interviewed the administrator and facility staff.

The administrator denied the allegation and stated that she is physically at the facility 3 times per week and at least 8 hours per day. In addition, she stated that she is available by phone.

LPA interviewed facility staff and they reported that the administrator is at the facility 2-3 times per week and they were able to reach her via phone when she is not at the facility.

After the investigation, this allegation is deemed to be unsubstantiated as there is no additional details provided by the reporting party and facility staff reported that the administrator is at the facility 2-3 times a week and they were able to get hold of her via phone when needed.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20231226104337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE
FACILITY NUMBER: 385600428
VISIT DATE: 03/05/2024
NARRATIVE
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Regarding to allegation of licensee does not ensure facility is adequately staffed to meet residents' medication needs, and facility staff are not properly dispensing medication as prescribed- there is no additional information provided by the reporting party. However, during the initial reporting, the reporting party stated that due to lack of medication technicians (med tech), residents are left without medications for an entire shift.

As part of the investigation, LPA reviewed records, interviewed the administrator and residents.

LPA interviewed the administrator who denied the allegation and stated that there was a med tech assigned everyday to assist residents with their medication.

Based on the staffing schedule and timecards of the med techs for the period of 12/16/2023 - 12/31/2023, it revealed that there was a med tech on the shift to administer medication for residents.

LPA interviewed 3 residents and all of them reported that the med tech is administering their prescribed medication on time and they do not recall the facility of not having a med tech.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed. A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20231226104337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/06/2024
Section Cited
CCR
87212(a)
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87212 Emergency Disaster Plan (a) Each facility shall have a disaster and mass casualty plan of action. The plan shall be in writing and shall be readily available.
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The administrator/licensee shall develop a plan to ensure facility staff is trained on the location of emergency disaster plan. The plan shall indicate when the training will be conducted.
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This requirement is not met as evidenced by facility staff stated that the emergency disaster plan is not readily available which poses an immediate health and safety risks for resident in care.
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The administrator/licensee will provide a copy of the plan to CCL by 3/6/2024. In addition, the administrator/licensee will provide a copy of the staff training record(s) to CCL upon completion.
Type A
03/06/2024
Section Cited
HSC
1569.695(b)
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ยง1569.695 Emergency Plans..(b) A facility shall provide training on the plan to each staff member upon hire and annually thereafter. The training shall include staff responsibilities during an emergency or disaster.
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The administrator/licensee shall develop a plan to ensure emergency disaster training is completed accordingly and on the plan the administrator will include when the training will be held.
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This requirement is not met as evidenced by facility was not able to provide a copy of the emergency disaster training records for staff members which poses an immediate health risk for residents in care.
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The administrator will provide a copy of the plan to CCL by 3/6/2024

In addition, the administrator/licensee will provide a copy of the training record(s) to CCL upon completion.
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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20231226104337
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: VILLAGE AT HAYES VALLEY-LAGUNA BUILDING, THE
FACILITY NUMBER: 385600428
VISIT DATE: 03/05/2024
NARRATIVE
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LPA interviewed 4 staff members and 2 of them reported that the last emergency disaster training was conducted 3-4 years ago; 1 stated that he/she was hired last year and he/she was never trained on emergency disaster plan; and 1 stated that he/she was hired in January, 2024 and was aware of the emergency disaster plan as the administrator was updating it.

Furthermore, all of them reported that they did not know where a copy of the emergency disaster plan is located at the facility.

After the investigation, this allegation is deemed to be substantiated as the facility staff was not trained on the emergency disaster plan and a copy is not readily available.

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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5