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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380540292
Report Date: 07/19/2022
Date Signed: 07/19/2022 02:00:55 PM


Document Has Been Signed on 07/19/2022 02:00 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:
07/19/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Administrator Christina SpenceTIME COMPLETED:
02:15 PM
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On 5/14/2022, the facility reported a serious incident concerning resident #1 (R1) who was not in the apartment and later was found in a private balcony four stories under his/her apartment, unresponsive, in a seating position with head injury. Licensing Program Analyst (LPA) Murial Han made a case management visit on 5/20/22 regarding the incident and initiated an investigation.

On 7/19/2022, LPA conducted a follow-up visit to deliver the findings of the investigation.

During the investigation the Department collected documentation and conducted interviews.

The coroner reported to the facility that the incident was due to self-inflicted harm. Staff reported that R1 was checked on a few hours prior to the incident, and did not observe anything unusual. In addition, R1 has never shown any behaviors of self-harm.

Based on interviews conducted and information from the coroner's office, there is no preponderance evidence of lack of supervision and neglect from the facility, therefore, this incident is deemed to be unfounded.

No deficiency cited. This report is discussed and reviewed with the 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: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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