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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600428
Report Date: 03/08/2023
Date Signed: 03/08/2023 12:24:21 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
01/26/2023 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230126111153
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: 19DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Interim Executive Director, Amanda NorthTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility does not have necessary supplies to care for resident's incontinence needs
Facility did not report unusual incident to CCL as required
INVESTIGATION FINDINGS:
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On 3/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230126111153. LPA Han met with interim executive director and explained the purpose of the visit.

Regarding to allegation of- facility does not have necessary supplies to care for resident's incontinence needs, there is no additional information forthcoming from the reporting party but during the initial reporting, the reporting party stated that there was always low or no supplies of wipes or diapers to care for resident's incontinence needs.

As part of the investigation, LPA conducted facility tour, interviewed administrator, residents, interviewed family members and facility staff.

During the facility tour, LPA observed 7 resident rooms on the 1st floor, 7 resident rooms on the 2nd floor, 8 resident rooms on the 3rd floor, supply closet on each floor, and the main storage room on the lower level. LPA observed wipes and diapers in resident's room, however, none in the closet rooms and in the main storage room.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
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 6
Control Number 14-AS-20230126111153
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: 03/08/2023
NARRATIVE
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According to 3 residents and 2 family members, they purchased their own incontinent supplies but the facility staff would take them for other residents as the facility often did not have any available.

The facility staff acknowledged that they would use resident's personal incontinent supplies for other residents when the facility ran out of supplies especially wipes.

According to the administrator, the facility has enough incontinent supplies such as wipes and diapers to care for the residents and the facility orders them weekly but the orders have to be approved by the corporate office first.

Based on the purchasing records provided by the facility on January 31, 2023, the last purchase of disposable wipes was made on December 1, 2022.

Based on interviews, record reviews, and observations during the course of the investigation, this allegation is deemed to be substantiated despite LPA observed wipes in resident rooms as family members reported that staff was using the wipes that they personally purchased for the other residents, and staff validated the family member's reporting as the facility did not have any supplies available. In addition, LPA observed there was no supplies in the supply closets. Furthermore, the last purchase of disposable wipes was done in December 2022.

Regarding to the allegation of- facility did not report an unusual incident to CCL as required, there is no additional information forthcoming from the reporting party but during the initial reporting, the reporting party stated that resident #1 (R1) AWOL (Absent Without Official Leave) on January 19, 2023 and the reporting party is concerned that the incident was not reported to CCL.

According to the administrator, this incident was reporting to CCL on January 20, 2023 via the Unusual Incident Injury Report as known as the LIC 624.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 14-AS-20230126111153
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: 03/08/2023
NARRATIVE
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Based on the documents provided by the facility, LPA observed a LIC 624 concerning this incident was completed. However, the facility was not able to provide proof that CCL was notified on January 20, 2023. In addition, there is no record of such incident was reported to CCL.

Based on record reviews, and observations, this allegation is deemed to be substantiated.

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 interim executive director.

A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
01/26/2023 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20230126111153

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: 19DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Interim Executive Director, Amanda NorthTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Facility does not ensure records are secure
INVESTIGATION FINDINGS:
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On 3/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230126111153. LPA Han met with interim executive director and explained the purpose of the visit.

Regarding to the allegation of- facility does not ensure records are secure, there is no additional information forthcoming from the reporting party but during the initial reporting, the reporting party stated that documents were left outside on the street in the rain around January 1, 2023; caregiver staff have pictures of the incident.

As part of the investigation, LPA interviewed the administrator who stated that he/she has heard something about the allegation that happened to this facility or the sister facility across the street but there was no specific details that was provided. In addition, the administrator stated that he/she never saw any pictures of the documents that were left on the street and the facility did not have any missing documents.

After the investigation, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

This report is reviewed and discussed with the interim executive director.

A copy is provided.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
01/26/2023 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20230126111153

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: 19DATE:
03/08/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Interim Executive Director, Amanda NorthTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
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Medication is accessible to residents in care
INVESTIGATION FINDINGS:
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On 3/8/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20230126111153. LPA Han met with interim executive director and explained the purpose of the visit.

Regarding to the allegation of- medication is accessible to residents in care, there is no additional information forthcoming from the reporting party but during the initial reporting, the reporting party stated that there was medication left in residents' room and the medication draw was left unlocked.

After part of the investigation, LPA conducted a tour of the facility and entered rooms on each floor and did not observe medications left in the rooms and the medication carts on each floor was locked.

After the investigation, this allegation is deemed to be unsubstantiated.

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 interim executive director.

A copy is provided
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 14-AS-20230126111153
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: 03/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/09/2023
Section Cited
CCR
87307(a)(3)
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87307 Personal Accommodations and Services..(a)Living accommodations(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident.
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Licensee shall conduct rounds to ensure the facility has sufficient supplies to care for residents. Licensee shall develop a plan of action to ensure the facility has adequate incontinent supplies to care for resident at all times.
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This requirement is not met as evidence by the facility did not have incontinent supplies to care for residents which poses an immediate health risk for residents in care.
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The facility will provide a copy of the plan to CCL by 3/9/2023.
Type B
03/15/2023
Section Cited
CCR
87211(a)(2)
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87211 Reporting Requirements..(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(2) Occurrences,..catastrophes or major accidents which threaten the welfare, safety or health of residents,...
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Licensee shall develop a plan of action in writing describing how the facility will report incidents according to the regulation. Plan of correction to include plan to train staff.
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This requirement is not met as evidence by: resident #1 (R1) AWOL and the facility was not able to provide proof that the incident was reported to CCL which posed an immediate health risk to resident in care.
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License will provide a copy of the plan and a copy of the education record by 3/15/2023.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6