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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 05/03/2023
Date Signed: 05/03/2023 12:55:21 PM


Document Has Been Signed on 05/03/2023 12:55 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: 67DATE:
05/03/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Sales Director, David EstradaTIME COMPLETED:
01:05 PM
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On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility.

On 5/1/2023, facility reported resident #1 (R1) was admitted to a skilled nursing facility on 1/20/2023 and returned on 4/26/2023 at 5PM.

On 4/27/2023 at 1:30AM, a caregiver provided care to R1 and at 2:30AM, the same caregiver witnessed R1 to be unresponsive. Caregiver notified a med tech who observed R1 to be pale with no pulse then proceeded with calling 911. At 3:10AM, R1 was pronounced by 911. At 10AM, R1 was picked up by Coroner and taken to the mortuary.

During today's visit, LPA requested for documents; LIC 602, reappraisal, service plan, hospital records and facility documentation to be submitted to CCL by 5/4/2023.

No deficiency cited today.

This report is discussed and reviewed with sales director.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 05/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/03/2023
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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