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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540292
Report Date: 05/20/2022
Date Signed: 05/20/2022 12:46:51 PM


Document Has Been Signed on 05/20/2022 12:46 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:SAN FRANCISCO TOWERSFACILITY NUMBER:
380540292
ADMINISTRATOR:CHRISTINA SPENCEFACILITY TYPE:
741
ADDRESS:1661 PINE STREETTELEPHONE:
(415) 776-0500
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY:350CENSUS: 306DATE:
05/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator, Christina SpenceTIME COMPLETED:
12:55 PM
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On 5/20/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced Case Management visit concerning a serious incident that was reported by the facility. LPA met with administrator, Christina Spence and health services administrator, Ryan Banner and explained the purpose of the visit.

On 5/14/2022, facility reported a serious incident that took place on 5/14/2022 concerning resident #1 (R1).

During today's visit, LPA requested for the following documents for R1:

- LIC 602 (Physician's Report)- will email by noon of 5/23/2022
- Service Plans- will email by noon of 5/23/2022
- Recent Hospital Records - will email by noon of 5/23/2022

LPA collected the following documents during the visit:

- Facility care staff work schedule
- Security officer work schedule for 5/13/2022 - 5/14/2022

This incident requires further investigation.

This report is reviewed and discussed with 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: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
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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