385600428-9-10-2024-14-AS-AMEN-D96LTA-20240916090202

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:46:42 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
05/28/2024 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240528100558

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:	10:30 AM
MET WITH:			TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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8
9

• Staff are mishandling resident medication

INVESTIGATION FINDINGS:

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13

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. In regard to allegation of resident medication being mishandled, there is not enough specific information provided in complaint to determine which resident and which medication is being referred to. LPA gathered information on the initial complaint visit on 5/29/2024 including reviewing random resident medication logs and could not determine if any resident medication was not given as prescribed.

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)

Page: 1 of 3

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
05/28/2024 and conducted by Evaluator John Calandra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240528100558

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:	10:30 AM
MET WITH:			TIME COMPLETED:	11:30 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

• Facility is not handicap accessible to residents in care.

INVESTIGATION FINDINGS:

1
2
3
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5
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7
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11
12
13

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. Regarding allegation regarding a violation that facility is not ADA compliant, i.e. handicap accessible, it was determined to be true. At the front entrance to facility, the handicap button to open the door was not operating or functioning. Resident’s that are disabled and unable to open the door by regular means should have access to the facility just as other residents do who are not disabled.

Based on the investigation, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. The deficiencies cited on the following page is in violation of the California Code of Regulations, Title 22, Division 6, Chapter 8:. Failure to correct said deficiencies may result in additional civil penalties.

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.

Substantiated

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)

Page: 2 of 3

Control Number 14-AS-20240528100558

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 09/10/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/10/2024 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303(a) Maintenance and Operation: a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Deficiency closed of 9/10/2024 as facility has ceased to operate as a community care facility.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by 1 out of 1 main doors which has a handicap accessible button that LPA observed as non operational, which is a potential health/safety risk to persons in care.	8 9 10 11 12 13 14
	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: 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 appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC9099 (FAS) - (06/04)

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