<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 04/04/2022
Date Signed: 04/05/2022 05:03:46 PM


Document Has Been Signed on 04/05/2022 05:03 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:SEQUOIAS SAN FRANCISCO (THE)FACILITY NUMBER:
380500593
ADMINISTRATOR:GLEN GODDARDFACILITY TYPE:
741
ADDRESS:1400 GEARY BLVDTELEPHONE:
(415) 922-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:400CENSUS: 270DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Health Administrator, Laleen DattTIME COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 4/4/22, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted the health administrator, Laleen Datt. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds with facility director, Carol Blackwell. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels, hand washing instruction is posted by the hand washing stations. All staff are being screened via Accushield as they enter the facility in the baseman and the security officer monitors and ensures staff is properly screened upon entering the facility. The facility has ready- to - go isolation carts set-up with PPE supplies and donning and doffing signs are posted on the isolation carts. The Environmental Services Director conducts PPE inventory counts every week and the facility orders PPE supplies according to the burn- rate calculation.

Medications are locked in the medication rooms in the assisted living and the memory care units. A comfortable temperature is maintained, lighting is sufficient for comfort. The high touched areas are being disinfected 2x/shift.

LPA requested for the following documents to be submitted to CCL by Wednesday 4/6/2022
- A copy of the current administrator certification, LIC308 Designation of Administrative Responsibility, LIC 309 Administrative Organization, and LIC 400 Affidavit Regarding Client/Resident Cash Resources

No deficiency cited today.
This report is reviewed and discussed with the health administrator. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/04/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1