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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 03/04/2024
Date Signed: 03/04/2024 12:37:28 PM

Unfounded


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
02/12/2024 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20240212152813
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
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Med-Tech - Theresa MartinezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility does not have a signal system for residents
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/04/2024, LIcensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with Med-Tech Theresa Martinez and explained the purpose of today's visit.

During the investigation LPA conducted interviews and made observations. According to interviews conducted, there is a pendant system in place. Some residents use the pendants and some use phones to call care staff such as the med-tech. Staff also rountinely check in on residents to provide supervision. The pendant system is operational and when pressed it goes to pagers care staff carry and displays location assitance is needed. This allegation is unfounded.

This agency has investigated the complaint alleging, Facility does not have a signal system for residents. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.
Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
02/12/2024 and conducted by Evaluator Jaime Vado
COMPLAINT CONTROL NUMBER: 14-AS-20240212152813

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
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Med-Tech - Theresa MartinezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility is changing its plan of operation without licensing approval
- Facility staff neglected to assist a resident who had fallen
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 03/04/2024, LIcensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings regarding the allegations received. LPA met with Med-Tech Theresa Martinez and explained the purpose of today's visit.

During the investigation LPA conducted interviews and made observations. The facility's plan of operation did not change but rather a service charge was to be assesed as an increase but that was since not enacted. The charge was never passed on so the original laundry plan is still in place. Garbage services are still in place as it were before as well on the original schedule. In regards, to an unwitnessed fall, LPA could not determine the length of time the resident was down before assistance was provided. Staff interviewed indicated that is too long and they normally would be able to observe and assist. On the third floor this resident resides they are the only double assist resident. As the fall was unwitnessed LPA cannot determine neglect nor the length of time accurately. These allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Theresa.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 2