385600423-9-17-2020-14-AS-KHOS-CSBN83-20230530101339

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 09/17/2020
Date Signed: 09/17/2020 05:51:35 PM

Substantiated

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
08/03/2020 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200803161119

FACILITY NAME:	SAGEBROOK SENIOR LIVING AT SAN FRANCISCO		FACILITY NUMBER:	385600423
ADMINISTRATOR:	ANGELA L BOUCHER-TURIN		FACILITY TYPE:	740
ADDRESS:	2750 GEARY BLVD		TELEPHONE:	(415) 346-0246
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY:	111	CENSUS:	DATE:	09/17/2020
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Angela Boucher-Turin		TIME COMPLETED:	05:30 PM

ALLEGATION(S):

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Uncleared adults
Facility staff failed to treat residents with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced tele-inspection visit to deliver the findings for the above allegations. LPA met with administrator Angela Boucher-Turin.

During the course of the investigation photos and screen shots of a text message group chat among staff, reviewed faciltiy LIC500 and checked facility staff fingerprint clearances and associations. Regarding the photo image recived, the photo was taken without resident consent and shows the residents sitting on a couch in an undisclosed location in the facility. Within the text message group chat image reveiwed, several staff persons commented on the photo of the residents inappropriately not giving the residents which shows staff is not providing them with their dignity or respect.

Continued on next page LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

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

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 14-AS-20200803161119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 FRANCISCO	FACILITY NUMBER: 385600423
	VISIT DATE: 09/17/2020

NARRATIVE

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PAGE 2 - LIC9099

Regarding uncleared adults, It is found that a staff person, S1, is not associated to the facility nor has a current finger print clearance going as far back as May 26, 2020. S1 appears on facility's LIC500 but no fingerprint clearance or association could be located within department databases. This violation incurs a civil penalty of $100 a day at five days for a first time offense. $100 x 5 (days) = $500. See related LIC421B.

Based on these findings, the allegation is SUBSTANTIATED. The allegation is valid because the preponderance of the evidence standard has been met, therefore Substantiated. The following deficiency was cited per California Code of Regulations Title 22 – refer to 9099D.

Report discussed with administrator and process in which the facility will receive a copy of this report and the e-signing of this document. A copy of this report is sent to administrator Angela Bouchir-Turin at 1735hrs on September 17, 2020. Administrator will sign and send back to LPA via e-mail.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 14-AS-20200803161119

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 FRANCISCO	FACILITY NUMBER: 385600423
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/17/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 09/18/2020 Section Cited CCR 80019(e)(1)	1 2 3 4 5 6 7	CRIMINAL RECORD CLEARENCE (e)All individuals subject to a criminal record review...shall...(1) Obtain a California clearance or a criminal record exemption as required by the Department. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee shall submit a written Plan of Correction (POC) to LPA by 9/18/2020 facility will obtain Criminal Record Clearances for S1 and associate to the facility accordingly.
	8 9 10 11 12 13 14	Based on the review of LIC500 and fingerprint database search the licensee failed to ensure that a been obtained for S1, staff member, which poses an immediate Health, and Safety or Personal Rights risk to clients in care. Civil Penalty Assessed at $100 x 5 = $500. See LIC421B	8 9 10 11 12 13 14	Additionally, S1 is not to be present at the facility until they are fingerprint cleared and associated to the facility.*Staff person should be removed immediately on this day if present*
Type A 09/18/2020 Section Cited CCR 87468.1	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESIDENTS IN ALL FACILIITES (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement has not been met as evidenced by:	1 2 3 4 5 6 7	Licensee shall submit a written Plan of Correction (POC) to LPA by 9/18/2020 facility will provide LPA with a written plan to conduct additional training address the deficiency.
	8 9 10 11 12 13 14	Based on the evidence recieved in the form of photos of a text message group chat showing residents and comments made by staff the facility failed to show residents dignity and respect by having their photo taken without consent and staff making inappropriate comments on the photo.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2020

LIC9099 (FAS) - (06/04)

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