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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600428
Report Date: 03/21/2023
Date Signed: 03/21/2023 11:30:10 AM


Document Has Been Signed on 03/21/2023 11:30 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: 16DATE:
03/21/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Business Office Manager, Thinh TaTIME COMPLETED:
11:40 AM
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On 3/21/2023, Licensing Program Analyst (LPA) Murial Han conducted a case management visit to follow-up on an incident that was reported by the facility.

On 3/15/2023, facility reported to CCL of an allegation of fiduciary abuse involving a staff member and a former resident.

During today's visit, LPA interviewed resident, facility staff and collected documents.

According to the staff, there were no other residents affected by the allegation except for the resident-in-question (R1).

No deficiency cited today as this incident requires further follow-up.

This report is reviewed and discussed with the business office manager and the interim Executive Director who arrived during the exit.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 03/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/21/2023
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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