385600423-3-1-2021-14-AS-KHOS-BYYJFH-20210310060047

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 03/01/2021
Date Signed: 03/01/2021 10:10:43 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
11/25/2019 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20191125145436

FACILITY NAME:	SAGEBROOK SENIOR LIVING AT SAN FRANCISCO		FACILITY NUMBER:	385600423
ADMINISTRATOR:	IGNACIO LOPEZ III		FACILITY TYPE:	740
ADDRESS:	2750 GEARY BLVD		TELEPHONE:	(415) 346-0246
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY:	111	CENSUS: 57	DATE:	03/01/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Angela Boucher-Turin, Administrator		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

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Resident sustained fractures while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza made an unannounced subsequent complaint tele-visit with Administrator, Angela. LPA met with executive director, Angela and explained the purpose of the visit.

During the course of investigation and based on record review, R1's physician report and medical assessment and interviews. On 2/12/19 Memory Care tour of R1's room and staff interviews indicating plan in place for bolting furniture. On 2/12/19, LPA conducted staff interviews and obtained copies of R1's physician report and medical assessments which indicated procedure in place for bolting furniture. Therefore the allegation was unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is Unsubstantiated.

Report reviewed with Administrator, Angela.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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