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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 11:17:55 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 - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
11:30 AM
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On 11/3/21 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the investigation outcome concerning an incident that was reported to the Department on 9/20/2021 concerning Staff 1 (S1) alleged Staff #2 (S2) strongly pulled Resident #1 (R1)'s ponytail in the dinning room when asking R1 to sit down on the couch.

During the initial visit on 9/22/2021, LPA Han requested for documents, interviewed staff. reviewed records and observed R1 who appeared to be calmed and was lying down on the couch watching TV with other residents. R1 was not able to recall the incident.

LPA Han interviewed S2 who denied of pulling R1's ponytail and stated that he/she tapped R1's shoulder as R1 was leaving the dining to redirect R1 back into the dinning room to watch TV where S2 can continue to provide supervision.

LPA Han interviewed the Clinical Director and the Administrator regarding to the facility's investigation process. The facility followed their investigation protocols and determined that the allegation to be unsubstantiated, however as an abuse prevention, the facility has provided an in-service to staff on "Elder Abuse Reporting".

After the investigation, no deficient cited.
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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