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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 03/01/2022
Date Signed: 03/01/2022 02:17:28 PM

Document Has Been Signed on 03/01/2022 02:17 PM - It Cannot Be Edited

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: 21DATE:
03/01/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Acting Administrator, Elois ThomasTIME COMPLETED:
02:45 PM
NARRATIVE
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On 1/11/2022, Licensing Program Analyst (LPA) Han conducted an unannounced follow-up case management visit regarding an incident that was verbally reported to the Desk Duty LPA on 12/23/21.

The facility was served a notice dated 12/8/2021 stating that one of their staff had been excluded immediately and needed to be removed from the premises. On 12/23/2021, acting administrator Ms. Thomas contacted Desk Duty (LPA Charitra) inquiring about the exclusion of the caregiver. During the call, Ms. Thomas stated that the staff's last day was 12/17, and also stated that there had been an incident recently when a resident was asking the whereabouts of the caregiver because the caregiver owed her money. The resident had purchased scrubs for the caregiver. Desk Duty LPA requested a written report, which is required within 7-days of the facility being notified of the occurrence. Ms. Thomas indicated to Desk Duty LPA that additional information would be collected from the resident and the corresponding report would follow.

On 1/11/2022, LPA Han made a case management visit and requested, once again, a copy of the LIC 624 Unusual Incident/Injury Report; at the time, the acting administrator, Ms. Thomas reviewed the file, and was unable to locate the original; acting administrator indicated that one was probably faxed to CCLD, and she was unable to ask the Resident Care Director for further details due to no longer employed at the facility and she was not able to locate a copy of the report. LPA Han asked for a written report to be forwarded to her as soon as possible, and thus providing the acting administrator time to reconstruct the incident by questioning the resident, and providing the basic details of the situation.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 385600428
VISIT DATE: 03/01/2022
NARRATIVE
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Up to today 3/1/2022, the facility has failed to provide a written report on that incident the facility has failed to provide a safe and comfortable environment for the resident.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC 809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with acting administrator, Elois Thomas. Appeals Rights were given. A copy of report was provided.


Acting Administrator, Eloise Thomas is refusing to sign.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 03/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/01/2022 02:17 PM - It Cannot Be Edited


Created By: Murial Han On 03/01/2022 at 12:53 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 03/01/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/15/2022
Section Cited
CCR
87211(a)(1)(D)

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Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require,...(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days..(D) Any incident which threatens the welfare, safety or health of any resident,....
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Facility shall complete a LIC 624 Usual Incident Report and submitted to CCL by 3/17/2022.
Facility shall submit a written plan to ensure compliance with regulation 87211(a)(1)(D) and to ensure facility
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This requirement was not met as evidenced by: Based interviews, the facility failed to provide a copy of the LIC624 Unusual Incident/Injury Report that was requested by the Dest Duty LPA after a verbal report from the Administrator on 12/23/21. Up-to-today, the facility still has not provided a written report which poses potential health risks to residents in care.
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notifies CCL of any incident which affects the residents. The facility shall provide in-service to the staff on such plan and provide a copy of the sign-in record to CCL. The POC will be submitted to CCLD office by the POC due date 3/15/2022.
Type B
03/15/2022
Section Cited
CCR87468.1(a)(2)

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Personal Rights of Residents in All Facilities(a)Residents in all residential care..shall have all of the following personal rights:(2)To be accorded safe, healthful and comfortable accommodations....
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Facility shall submit a written plan to ensure compliance with this regulation. Facility shall provide an in-service to staff on such plan and submit a copy of the in-service sign-in record to CCL by the due date 3/15/2022.
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This requirement was not met as evidenced by a formal staff was asking a resident to purchase scrubs which poses potential health risks to residents in care.
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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:Julio Montes
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 03/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/01/2022


LIC809 (FAS) - (06/04)
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