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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 11/14/2020
Date Signed: 11/14/2020 04:21:12 PM

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:SAGEBROOK SENIOR LIVING AT SAN FRANCISCOFACILITY NUMBER:
385600423
ADMINISTRATOR:ANGELA L BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 55DATE:
11/14/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:13 PM
MET WITH:Todd MurrayTIME COMPLETED:
04:00 PM
NARRATIVE
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On 11/14/20 Licensing Program Analyst (LPA) Chris Hopkins conducted an unannounced case management. LPA met with Todd Murray via tele-visit due to Covid-19 procedures and explained the purpose of the tele-visit.

Given the present pandemic, this facility is being closely monitored by the local department of health (LDH) and Department of Social Services. This facility is required to submit a daily report (“linelist”) to both, LDH and Community Care Licensing (CCL) specifying any changes related to the pandemic. The facility has been inconsistent in submitting such linelist, and failed to submit it to CCL on 11/10, 11/11, and 11/12.

Furthermore, as part of the present pandemic, facilities are required to report any epidemic outbreak related issues within 24 hours. A staff tested COVID-19 positive on 11/6 and the case was not reported to CCL until 11/12. Moreover, LPA Raygoza requested staff roster on 11/11 and 11/12, but the roster was not submitted to CCL.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Travis. A a copy of this report was provided to Travis via email, due to COVID-19 precautionary measures
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 11/14/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/14/2020
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAGEBROOK SENIOR LIVING AT SAN FRANCISCO
FACILITY NUMBER: 385600423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2020
Section Cited

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87211 (a) Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require. This requirement is not met as evidenced by:
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The licensee failed to submit the required daily linelist on 11/10, 11/11 and 11/12 to CCL, which poses a potential health and safety risk to residents in care.
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Type B
11/16/2020
Section Cited

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87211(a)(2)-Reporting Requirements - Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate. This requirement is not met as evidenced by:
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A staff member tested positive for COVID-19 on 11/6, but facility failed to report such incident until 11/12. Licensee did not ensure the incident was reported within 24 hours which poses a potential health and safety risk to residents in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: SAGEBROOK SENIOR LIVING AT SAN FRANCISCO
FACILITY NUMBER: 385600423
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/14/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2020
Section Cited

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87412 (f) Personnel Records: All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. This requirement is not met as evidenced by:
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Facility failed to submit staff roster as requested by LPA Raygoza on 11/11 and 11/12, which poses a potential health and safety risk to residents in care.
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Christopher Hopkins-ClarkeTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 11/14/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/14/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3