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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 11/19/2020
Date Signed: 11/20/2020 08:42:49 AM

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:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrators, Angel Boucher-Turin and Tod MurrayTIME COMPLETED:
05:30 PM
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During today's PCC/TA visit following attendees:
Rebekah Bird-Wohlgemuth, HFEN
Brenda Chan, LPM
Bertha Raygoza, LPA
Tod Murray, Administrator
Cynthia Browning, Corp Nurse

LPH CONCERN; MCU- 3 NON COVID Residents residing in MCU POSITIVE area and delayed in moving into MCU NON COVID area LAPSE of 2 - 3 days
- Since then the above concern has been rectified, Staff will not cross over.
MCU - Day 14 on 11/20 and retest of all Non-Covid on 11/20/20
For Positives C19 of 11/6 quarantine completed on 11/20/20

Recommendations from PCC/TA visit of 11/09/20 as follows:
- Staff working at other facilities - To be provided by Angela, Administrator
- LPH State nurse request - Nurse Consultant - Allen Flores Consultant - Cynthia Browning
- Medication 30 day supply - Supply 30 day - Completed
- All signs isolation rooms/doors/medical equip - Completed

LPH CONCERN: Recommendations and concerns:
Concern of Staff cross over from MCU to AL /Staff providing care from MCU to AL
- cross over acceptable with the appropriate PPE donning and doffing procedures
- Positive staff of 11/15 from MCU assisted as caregiver to four AL residents and
currently all 4 (four) AL residents exposed are under PUI quarantined
- Staff Positive C19 of 11/15 will be off quarantine in 7 days or more.


SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAGEBROOK SENIOR LIVING AT SAN FRANCISCO
FACILITY NUMBER: 385600423
VISIT DATE: 11/19/2020
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Cont'd 809

Recommendations from HFEN:
- Carts replenished daily, donning and doffing PPE, sanitizing and hand washing
- Carts set up by each room /trash bin inside room / No co-mingling in MCU and AL
- PUI Group of 4 residents in AL tested 11/20 for exposure of Staff Positive of 11/15
- follow Strictest requirements and follow LPH


LPA to check on the following HFEN recommendations:
- Angela will submit list of staff working at other facilities
- Todd, will follow up on formula for disinfecting floors that meets EPA requirement
- Trash bins in PUI to be replaced with foot pedal in lieu of hand pedal currently in PUI
- Donning and doffing of gloves - CDC guidelines

This report was reviewed and discussed with Tod Murray, Administrator.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC809 (FAS) - (06/04)
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