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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 01/05/2023
Date Signed: 01/17/2023 04:03:32 PM


Document Has Been Signed on 01/17/2023 04:03 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
SF COASTAL AC/SC, 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:
01/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Resident Care Director, Jennine ChanTIME COMPLETED:
03:20 PM
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On 1/5/23, Licensing Program Analyst(LPA) Murial Han conducted an unannounced annual inspection. LPA observed COVID-19 signs posted by the entrance. LPA was greeted by the Resident Care Director, Jennine Chan. LPA explained the purpose of the visit and LPA was screened at the front entrance.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident and staff daily monitoring records, containment strategies, PPE supply and the environmental cleaning supply are adequate; bathrooms are equipped with soap and paper towels; COVID-19 signs are observed to be posted through-out the facility; residents have their own rooms except for couples; hand washing instruction is posted by the hand washing stations; hand sanitizers are observed at varies locations within the facility.

Residents and staff are being screened for COVID-19 on a daily basis and visitors when they entered the facility.

During the tour, LPA observed both medication rooms were open with staff members present and staff reported that the rooms are locked at all times when no one is there. First aide kits are observed to be equipped and stored in the medication rooms. A comfortable temperature is maintained, lighting is sufficient for comfort.

The facility appeared to be cleaned and tidy; dinning rooms are observed to be spacious, comfortable and furniture is spaced out.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAGEBROOK SENIOR LIVING AT SAN FRANCISCO
FACILITY NUMBER: 385600423
VISIT DATE: 01/05/2023
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During today's visit, LPA Han requested for the following documents to be submitted to CCL by 1/10/23:

-LIC308 Designation of Administrative Responsibility
-LIC500 Personnel Report
-Administrator Certificate

No deficiency cited today.

This report is reviewed and discussed with the Resident Care Director, Jennine Chan.

A copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2023
LIC809 (FAS) - (06/04)
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