385600428-3-5-2024-14-AS-KHOS-D3ALWK-20240312090717

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:56:41 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
02/29/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240229144948

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: 19	DATE:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maryanne Rodriguez		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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Facility is not conducting fire drills

INVESTIGATION FINDINGS:

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On 3/5/2024 Licensing Program Analyst (LPA), Murial Han conducted an unannounced 10-day complaint visit. LPA met with resident service coordinator and explained the purpose of today's visit.

Regarding to allegation of- facility is not conducting fire drills, the reporting party stated that facility staff members are not being trained on emergency/fire drills.

During the investigation of complaint # 14-AS-20231226104337 that was received by CCL on 12/26/2023, one of the allegations was related to this allegation as the reporting party reported that the facility did not conduct emergency safety training for facility staff and as part of the investigation, LPA requested for documents for fire/emergency drills that were conducted in 2023 and the facility was not able to provide it.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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)

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Control Number 14-AS-20240229144948

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 HSC 1569.695(c)	1 2 3 4 5 6 7	§1569.695Emergency Plans(c) A facility shall conduct a drill at least quarterly for each shift.. The requirement is not met as evidenced by the facility was not able provide proof that drills were conducted accordingly which	1 2 3 4 5 6 7	The licensee/administrator will develop a plan to ensure emergency/fire drills are conducted accordingly. In the plan, it shall indicate staff training and when will a drill be conducted.
	8 9 10 11 12 13 14	poses an immediate health and safety risks to residents in care.	8 9 10 11 12 13 14	The licensee/administrator will submit a copy of the signed and dated plan to CCL by 3/6/2024 and will provide a copy of the staff training record upon the completion of the drill.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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)

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Control Number 14-AS-20240229144948

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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In addition, LPA interviewed 4 staff members and 2 staff member reported that the last emergency disaster training/fire drill was conducted 3-4 years ago; 1 staff stated that he/she was hired last year and he/she was never trained on emergency disaster training/drills; and the last staff stated that he/she was hired in January 2024, he/she was trained on emergency disaster and has not participated in a fire drill.

After the investigation, this allegation is deemed to be substantiated.

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (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)

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