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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 07/19/2022
Date Signed: 07/19/2022 03:18:15 PM


Document Has Been Signed on 07/19/2022 03:18 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: 56DATE:
07/19/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Administrator, Fili HowardTIME COMPLETED:
03:30 PM
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On 7/19/2022 Licensing Program Analyst (LPA) Murial Han conducted an unannounced follow-up visit to deliver the outcome from the case management visit on 6/20/22 concerning an incident that was reported by the facility on June 3, 2022.

On June 3, 2022, CCL received a LIC624 (Unusual Incident/Injury Report) from the facility regarding resident #1 (R1) was delivering mail to resident #2 (R2) and was told by R2 not to touch the mail that does not belong to R1. R1 appeared upset, left the facility and went to a nearby store where R1 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 R1 was a resident at the facility.

Based on the documents provided by the facility, R1 is able to leave the facility unassisted, and according to staff, R1 enjoys to walk outside of the facility and returns when R1 is ready.

Concerning to resident's mail, staff stated that facility has a system to ensure mails are delivered to the residents on the day as they arrive. However, the mails were delivered late on the day prior to the incident and they were left on the receptionist desk. On the next morning, R1 got hold of them, took the mails that belonged to R2 and delivered them to R2 as a nice gesture but it was not appreciated by R2 which made R1 upset and left the facility. The staff also reported that there was no alteration between R1 and R2.

Based on record review and interviews, no deficient cited.

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: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
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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