385600428-9-10-2024-14-AS-AMEN-D96LGL-20240916084452

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:25:44 AM

Unsubstantiated

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
07/09/2024 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240709152730

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:	DATE:	09/10/2024
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:			TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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• Resident billed for services not rendered

INVESTIGATION FINDINGS:

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LPA John Calandra and LPM Andrea Medlin concluded this complaint today. LPA and LPM called facility representative to go over allegation findings on 9/5/2024 and left a voicemail message asking for a return call. As of today, September 10, 2024, Reporting Party has not returned call. LPA conducted initial complaint visit on 7/17/2024, however the facility was closed and appeared vacant. LPA attempted to call facility representative Regarding allegation of resident billed for services not rendered, there is not enough specific information provided in complaint to determine what services were billed and are in dispute. LPA has been unable to obtain copies of the bill regarding this allegation. LPA requested copies of this bill from reporting party on several occasions including: July 15th, July 29th, and August 26th, 2024. Since LPA was unable to obtain the relevant documents/bills, it is unknown what services were billed and in dispute.

Based on the Department's investigation, it was determined there was a lack of sufficient evidence to support or deny this allegation. Based on this information, the finding of this allegation is unsubstantiated.

This report was provided to facility by email and certified return receipt mail (since facility is closed and vacant) and a copy of this report must be made available for public review upon request.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John Calandra	TELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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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