385600359-8-29-2024-14-AS-DTOA-D8LUXP-20240829155840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600359
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:58:48 PM

Document Has Been Signed on 08/29/2024 03:58 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME:	CARLISLE-IVY SIGNATURE LIVING, THE		FACILITY NUMBER:	385600359
ADMINISTRATOR:	STEPHANIE SCHMAUTZ		FACILITY TYPE:	740
ADDRESS:	1450 POST ST		TELEPHONE:	(415) 929-0200
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY:	130	CENSUS: 93	DATE:	08/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jeffrey Brenner, Executive Director		TIME COMPLETED:	04:00 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	On 8/29/2024, Licensing Program Analysts (LPA's) Tobola & Jian conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Jeffrey Brenner. The facility currently provides care for 93 residents, 1 of which are receiving hospice services and some of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor and kitchen were found to be last charged on November 2023. Smoke and carbon monoxide detectors and fire safety systems are interconnected. Fire Safety Inspections completed on March 1, 2024 indicating all fire safety devices and systems to be in order. Water at faucets accessible to residents measured between 105.0 and 120.0 degrees F which is within regulation. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished twice per week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. Residents that were awake during the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. Residents were observed to have a positive and personable relationship with staff. Continued onto LIC809-C

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: CARLISLE-IVY SIGNATURE LIVING, THE	FACILITY NUMBER: 385600359
	VISIT DATE: 08/29/2024

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LPA conducted a sample file review for 9 residents and found all items to be on file. LPA's found that residents Needs & Service Plans are up to date, however the Executive Director is in the process of acquiring updated signatures from residents and family. Technical Violation issued. Upon a spot check of nine (9) staff files, LPA found that caregiver staff have current first aid and annual training on file. Lastly, A spot check of medications was conducted and found that all medication counts and records are in order.

Jeffrey Brenner's Administrator Certificate 6068069740 is currently active through 1/17/2026.

LPA requested the following documents be sent to CCL by COB 9/12/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during the visit.

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024

LIC809 (FAS) - (06/04)

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