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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:44:33 AM


Document Has Been Signed on 01/26/2023 11:44 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
385600428
ADMINISTRATOR:ELOIS THOMASFACILITY TYPE:
740
ADDRESS:624 LAGUNA STTELEPHONE:
(415) 318-8670
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94102
CAPACITY:56CENSUS: 23DATE:
01/26/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Executive Director, Elois ThomasTIME COMPLETED:
12:00 PM
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On January 26, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to a complaint visit made at Licensee's other facility, Village at Hayes Valley-The Grove Building, located across the street. LPA met with Executive Director, Eloise Thomas and explained the purpose of the visit.

During this visit, LPA requested to tour the kitchen and observe the cleaning supplies. According to the Executive Director, both facilities (Village at Hayes Valley- Laguna Building and Village at Hayes Valley- Grove Building) share cleaning supplies and it is stored in the basement of this facility. LPA observed the cleaning supplies with the Executive Director and the Maintenance Director. In addition, according to the Executive Director, there is one kitchen for the two facilities and it is located in this building. LPA toured the kitchen and spoke to the Lead Cook.

No citations are issued during the visit. LPA reviewed report with Elois Thomas and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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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