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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 11/03/2021
Date Signed: 11/03/2021 11:10:32 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:FAIMAFILI HOWARDFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 60DATE:
11/03/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
11:30 AM
NARRATIVE
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On 7/27/2021, the facility reported that a caregiver had been removed from the facility after it was found to have engaged in an inappropriate contact with a resident. The Department made a case management visit regarding the incident on 7/28/2021 and initiated an investigation. On 11/3/2021, Licensing Program Analyst (LPA) Murial Han conducted a follow-up to deliver the findings of the investigation.

The Department determined that on 7/26/2021, a staff member (S1) indicated to another staff (S2) intentions to give a resident (R1) a shower. After a few minutes, S2 went to assists S1 and found S1 with pants down and in underwear within the bathroom and in the presence of R1. S1 denied a sexual encounter but acknowledged an emotional relationship with R1; therefore, the S1 was removed from the facility immediately.

During the investigation, the Department collected documentation and conducted interviews. S1 denies engaging in sexual contact with R1 but acknowledges a relationship with the resident. R1 is unable to communicate and unable to acknowledge any relationship, and given R1’s health condition, unable to consent. No other staff acknowledged awareness of S1’s claimed relationship with R1.

Based on interviews conducted, there is preponderance evidence to show that S1 engaged in inimical behavior and engaged in inappropriate contact with a resident in care. Therefore, facility staff violated the resident’s personal rights.

Appeal rights and penalty assessments have been explained to Facility Representative, and the following Type A deficiency is cited based on Title 22, Division 6 of California Code of Regulations.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2021
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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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: 11/03/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/03/2021
Section Cited

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§1569.58 Persons prohibited from being a licensee,..(a) The department may prohibit any person from being a licensee,...or continuing the employment of, or allowing in a licensed facility, or allowing contact with clients of a licensed facility by, any employee, prospective employee,
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or person who is not a client and who has done any of the following:(2) Engaged in conduct that is inimical to the health, morals, welfare, or safety of either an individual in or receiving services from the facility, or the people of the State of California.
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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: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 11/03/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/03/2021
LIC809 (FAS) - (06/04)
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