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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 09/22/2021
Date Signed: 09/22/2021 01:45:24 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:FAIMAFILI HOWARDFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 50DATE:
09/22/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:20 AM
MET WITH:Jeannine ChanTIME COMPLETED:
02:00 PM
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On 9/22/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Clinical Director, Jennine Chan and explained the purpose of the visit.

The facility reported that Staff 1 (S1) alleged Staff 2 (S2) strongly pulled Resident 1 (R1)'s ponytail in the dining room when asking her to sitting down on the couch.

The Clinical Director conducted a skin assessment for R1 and no injuries were noted.

During today's visit, LPA interviewed staff, observed R1 and requested for documents.

This incident requires further investigation.

This report is discussed and reviewed with the Clinical Director. A copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2021
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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