385600428-1-17-2023-14-AS-CSMH-CNDV9W-20230124151502

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 01/17/2023
Date Signed: 01/17/2023 01:00:40 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
10/12/2022 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20221012144700

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: 22	DATE:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Administrator, Eloise Thomas		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Lack of care and supervision
Resident is not receiving medications as prescribed
Staff are not adequately trained

INVESTIGATION FINDINGS:

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On 1/17/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20221012144700. LPA Han met with administrator and resident service director and explained the purpose of the visit.

Regarding to allegation of - lack of care and supervision, resident - in - question (R1) reported that on weekends during the night shift, there is no caregivers at the facility because there was only 1 caregiver scheduled for 2 buildings (sister facility acrossed the street) and when this caregiver is called by the medication technician(med tech) to assist residents at the sister facility which resulted no help for residents in this facility. In addition, R1 stated that there were days on the weekends that the facility did not have a medication technician (med tech) on the night shift to assist R1 and other residents with their medications.

As part of the investigation, LPA requested multiple times both in writing and verbal to interview facility staff with no success. However, based on the facility's schedule/assignment from 10/16/2022 to 10/31/2022, LPA observed on the following dates, the facility did not have a med tech scheduled on the night shift: 10/20/2022, 10/21/2022, 10/22/2022, 10/28/2022, and 10/29/2022. In addition, LPA observed on the following dates, there only 1 caregiver for both facilities: 10/23/22, and 10/30/22.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

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 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 01/17/2023

NARRATIVE

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In addition to R1, LPA also interviewed resident #2 (R2) who also stated that quite often the facility did not have any med techs on the night shift and caregivers especially on the weekends.

Based on interviews and record reviews during the course of the investigation, this allegation is deemed to be substantiated as the administrator/licensee did not ensure facility shall at all times be sufficient in numbers of personnel, and competent to provide the services necessary to meet resident needs.

Regarding to allegation of- resident is not receiving medications as prescribed, the reporting party stated that R1 is not receiving his/her 5AM prescribed medication as there is no night shift med tech on duty.

As part of the investigation, LPA interviewed R1 and R2 and both of them reported that they have prescribed medications to be taken before breakfast and these medications should be administered by the night shift med tech who works from 10pm- 6:30am but when none is scheduled, the evening shift med tech who works from 2pm- 10:30pm would give them these medications at 10pm for them to take it by themselves on next morning before breakfast.

LPA interviewed the evening shift staff #1 (S1) who reported that there were weekends without night shift med tech to relieve S1 so before S1 ends the shift, S1 would give R1 and R2 their 5AM medication(s) so they could administer it by themselves before the breakfast next day.

Based on R1 and R2's Medication Administrator Records, it indicated that both residents have morning medication prescribed by their physician.

Based on the staffing scheduled provided by the facility, it also indicated that there was no med tech(s) scheduled on the night shift for multiple days in October, 2022.

According to the administrator, the facility is utilizing agency for caregivers but not med tech(s).

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 01/17/2023

NARRATIVE

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Based on interviews, observations and record reviews, this allegation is substantiated as the administrator/licensee did not arrange or assist in arranging to meet the medical needs of residents with assisting R1 and R2 to take their prescribed medications as their early morning medication was given to them hours in advance for them to take it by themselves due to lack of night med tech.

Regarding to allegation of - staff are not adequately trained, the reporting party and R1 were questioning if the facility staff who assists resident with self-administration of medication are properly trained and certified.

According to the training records provided by the facility for 4 staff members who assists resident with self- administration of medication and LPA observed S1 has completed 2 hours of training in 2018 and a competency verification: oral medication review on 8/1/2022, staff #2 (S2) has completed 3 hours of training in 2021 and a competency verification: oral medication review on 8/1/2022; staff #3 (S3) has completed 2.25 hours of training in 2022 and a competency verification: oral medication on 8/1/2022; Staff #4 (S4) has completed a competency verification: oral medication review.

Based on the records above, the facility staff members assisting residents with self-administration of medication have not completed their training requirements in accordance to Title 22, Division 6 Health and Safety Code under §1569.69 Employees assisting residents with self-administration of medication; training requirements. (a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements:
(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. (b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication related issues in each succeeding 12-month period.

Based on observations, interviews and record reviews during the course of the investigation, this allegation is deemed to be substantiated.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 01/17/2023

NARRATIVE

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Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, these allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the administrator.

A copy of this report and Appeal Rights were provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 8 of 8

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
10/12/2022 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20221012144700

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:	01/17/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:			TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Resident did not receive food services
Facility paging system is not in good repair

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
	VISIT DATE: 01/17/2023

NARRATIVE

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Regarding to facility paging system is not working, the reporting party stated R1 used the call pendant for assistance but no one responded so R1 attempted to call someone from a cell phone which may or may not reach anyone.

As part of the investigation, LPA interviewed R1 who provided the same details as the reporting party and stated that it was uncertain if the call pendant system was working or not as no one answered it.

According to the administrator, the call pendant system was working and it was recently checked by staff and a 3rd party agency, Stanley Healthcare on 10/12/2022.

Based on the documents provided by the facility, LPA observed that the paging, pager and call pendant systems were working properly. In addition, facility staff documented on 10/4/2022, that R1's pendant was checked and cleaned.

Based on observation, record review and interviews during the course of the investigation, this allegation is deemed to be unsubstantiated as the facility provided documentation that the call and paging systems were checked. However, as R1 reported that no one responded to the call pendant and no one answered the call could be related to insufficient staffing to assist resident needs which is already addressed on LIC 9099 and LIC9099D.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

This report is reviewed and discussed with the administrator.

A copy is provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2023 Section Cited CCR 87411(a)	1 2 3 4 5 6 7	87411 Personnel Requirements - General(a)Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.....This requirement is not met as evidence by:	1 2 3 4 5 6 7	The administrator and/or licensee will develop a plan to ensure and to validate that the facility has sufficient number of staff to provide services to residents in need.
	8 9 10 11 12 13 14	Based on resident interviews and observation of the facility's work schedule/assignment, there were lack of caregiver(s) and medication technicians on the night shift which posed an immediately health risk for residents in care.	8 9 10 11 12 13 14	The facility will provide of copy of the plan by the due date of 1/18/2023 Civil penalty is being assess today as the same deficiency was issued on 3/29/2022.
Type A 01/18/2023 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care(a)A plan for incidental medical...shall be developed by each facility) The licensee shall arrange, or assist in arranging, for medical care appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure residents needs are being met including but not limiting to administration of medication.
	8 9 10 11 12 13 14	This requirement is not met as evidence by: due to lack of staff to assist R1 and R2's prescribed medication, R1 and R2 had to take it by themselves which posed an immediate health safety risk to resident in care.	8 9 10 11 12 13 14	The administrator/license will submit a copy of the plan by the due date of 1/18/2023.

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 14-AS-20221012144700

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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, THE	FACILITY NUMBER: 385600428
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/17/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/18/2023 Section Cited HSC 1569.69	1 2 3 4 5 6 7	§1569.69 Employees assisting residents with self-administration of medication; training requirements(a) Each residential care facility for the elderly licensed..) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	The administrator and/licensee will develop a plan to ensure all facility staff who assist residents with self-administration of medication completes the training requirement.
	8 9 10 11 12 13 14	ased on training records provided by the facility, LPA observed 4 out of 4 facility staff who assist residents with self-administration of medication is not qualified which posed an immediate health and safety risk to residents in care.	8 9 10 11 12 13 14	The facility will submit a copy of the plan by the due date of 1/18/2023.
	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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 01/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 8