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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 06/20/2022
Date Signed: 06/20/2022 12:26:55 PM


Document Has Been Signed on 06/20/2022 12:26 PM - It Cannot Be Edited

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: 71DATE:
06/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
12:45 PM
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On June 20, 2022, Licensing Program Analyst (LPA) Murial Han conducted an case management visit regarding an incident that was reported to CCL. LPA met administrator and explained the purpose of the visit.

On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 was delivering mail to resident #2 and was told by resident #2 not to touch the mail that does not belong to resident #1. Resident #1 appeared upset, left the facility and went to a nearby store where resident #1 was witnessed by a bystander performing an unusual activity which triggered the bystander to call 911. In addition, the bystander also called the facility to confirm resident #1 was a resident at the facility.

After the facility was notified by the bystander of a potential resident, facility staff went to the nearby store and confirmed that it was resident #1. Resident #1 returned to the facility later on that same day after the hospital stay.

During today's visit, LPA interviewed the administrator and collected some documents and addition documents- Care Plans, and medical records will be provided by 6/21/22.

This incident requires further follow-up.

This report is reviewed and discussed with the administrator.

A copy is provided.


SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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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