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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 11/03/2021
Date Signed: 11/03/2021 11:42:17 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210914092034
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: 60DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff were not responsive to resident's calls for assistance.
Facility is not in good repair.
INVESTIGATION FINDINGS:
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On 11/3/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings. LPA Han met with the Administrator and explained the purpose of the visit.

Regarding to allegation of- staff were not responsive to resident's calls for assistance. LPA Han interviewed the Clinical Director who denied the allegation. LPA Han interviewed residents regarding the call for assistance response time and they reported that the staff is very helpful, very nice and very attentive. After investigation, this allegation is deemed to be unsubstantiated.


Regarding to allegation- facility is not in good repair, the Maintenance Director reported that there was a leak in one of the rooms a few months ago that caused by an accident and it was fixed within a couple of hours. LPA Han toured the facility and residents' rooms and observed all of them were cleaned, no cracks, no leaks, and no signs of any damages. LPA Han interviewed residents who have been residing at the facility from the range of 9 months to 5 years and all of them reported that the facility is in good shape. After the investigation, this allegation is deemed unsubstantiated.

This report is reviewed and discussed with the Administrator. A copy is provided.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20210914092034

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: 60DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not safeguard resident's personal belongings.
INVESTIGATION FINDINGS:
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Regarding to allegation of- facility did not safeguard resident's personal belongings, the Reporting Party reported that the leak from the ceiling spilled down on the duvet on her bed and the staff proceed putting the dry clean only duvet through the washer and ruining it. The Reporting Party spoke to the previous Administrator who agreed to pay for it.

LPA Han interviewed staff regarding the above allegation and staff acknowledged that the duvet was accidentally damaged after being washed in a regular washer instead of dry clean and the staff did not know if the Reporting Party was reinbursed. After the investigation, this allegation is deemed to be substantiated.

Based on interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22, Division 6 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20210914092034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 B
11/24/2021
Section Cited
CCR
87217(b(
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SAFEGUARDS FOR RESIDENT CASH, PERSONAL PROPERTY AND...(b) Every facility shall take appropriate measures to safeguard residents'..personal property and valuables which have been entrusted to the licensee or facility staff.....
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If the facility has not reimbursed the resident the facility shall do so by the due date 11/24/2021
The Administrator will in-service housekeeping staff on proper ways to safeguard residents' personal belongs.
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This requirement is not met as evidenced by the facility proceeded to put a dry clean duvet in a regular washer which posed potential health and safety risks to resident in care.
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The Administrator will provide a copy of the lesson plan and a copy of the sign-in sheet by the plan of correction due date 11/24/2021.
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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
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/14/2021 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20210914092034

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: 60DATE:
11/03/2021
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adminstrator, Fili HowardTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Facility did not providing safe accommodations to residents.
Staff did not respect resident's privacy.
INVESTIGATION FINDINGS:
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Regarding the allegation of- facility did not provide safe accommodations to residents, the Reporting Party is alleging that during their visit, the receptionist left at 5pm and the Reporting Party was told that the door locks at 7pm, however, the Reporting Party was told on the next day that the door was not locked until 8pm due to daylight saving and it was unsafe for Resident #1 (R1) as anyone could entered the building.

LPA Han interviewed the staff members who denied the above allegation and stated that the door locks automatically at 5pm and there is a sign with a phone number posted by the door for the visitors to call one of the Medication Technicians who opens the door accordingly. LPA Han interviewed the residents and all of them reported of feeling safe at the facility. There is no additional information forthcoming from the Reporting Party. After investigation, this allegation is deemed to be unfounded.

Unfounded
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20210914092034
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/03/2021
NARRATIVE
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Regarding to allegation of- staff did not respect resident's privacy, the Reporting Party is alleging that while staff #1(S1) was showering Resident #1 (R1), two other staff barged into the bathroom room despite R1 asked them not to. LPA interviewed S1 who denied the allegation and stated that the two staff asked for R1's permission and R1 agreed to it. In addition, S1 stated that he/she used a towel to cover R2 before the two staff entered the bathroom. There was no additional information forthcoming from the Reporting Party. After investigation, this allegation is deemed unfounded.

This agency has investigated the complaint. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

This report is reviewed and discussed with the Administrator. A copy is provided.
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
LIC9099 (FAS) - (06/04)
Page: 5 of 5