385600423-5-31-2023-14-AS-KHOS-CSHPZP-20230605114552

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 05/31/2023
Date Signed: 05/31/2023 02:42:29 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
04/27/2023 and conducted by Evaluator Murial Han

COMPLAINT CONTROL NUMBER: 14-AS-20230427140227

FACILITY NAME:	SAGEBROOK SENIOR LIVING AT SAN FRANCISCO		FACILITY NUMBER:	385600423
ADMINISTRATOR:	FAIMAFILI HOWARD		FACILITY TYPE:	740
ADDRESS:	2750 GEARY BLVD		TELEPHONE:	(415) 346-0246
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY:	111	CENSUS: 59	DATE:	05/31/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Administrator, Fili Howard		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Facility did not repair resident's window.
Facility radiator heater is leaking.
Facility placed a hazardous item next to resident's bed.

INVESTIGATION FINDINGS:

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On 5/31/2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20230427140227. LPA Han met with administrator and explained the purpose of the visit.

Regarding to allegation of - facility did not repair resident's window, the reporting party stated that resident #1 (R1) has been residing at the facility for 2 years and the window in the room has never operated correctly. The responsible party and the reporting party has made many requests verbally and in writing to fix the window but it is still inoperable.

As part of the investigation, LPA toured R1's room, interviewed maintenance director, administrator and reviewed written communication correspondences.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

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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Control Number 14-AS-20230427140227

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/31/2023

NARRATIVE

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According to the maintenance director, he/she was made aware of the broken window since December 2022. In addition, the maintenance director stated that a window company came to the facility a few months ago to assess the window and determined that it needed to be replaced and provided a quote for the replacement. Furthermore, the maintenance director stated that the quote was submitted to the corporate office for approval.

The administrator acknowledged that R1's window has been broken for a long time and the facility is in process of getting it replaced. The administrator stated that the responsible party was offered to have R1 move into another room while waiting for the replacement.

Based on the documentation provided by the facility, on January 1, 2022, the responsible party informed the administrator in writing that R1's window has been broken for 10 months, this safety concern has been reported to facility staff but it was not addressed. A year later on Jan 18, 2023, the window was still not fixed and/or replaced. The responsible party requested the facility to fix it immediately or move R1 to another room and subsequently, R1 was offered to move to another available room.

During the initial complaint visit on 5/3/2023, LPA observed R1's window was not fixed and there were towels by the window seal to keep it open.

After the investigation, this allegation is deemed to be substantiated as R1's window has been broken since 2021 and it was reported to facility staff and directors. R1 was offered another room, however, it was done a year later requested by the responsible party.

Regarding to allegation of- facility radiator heater is leaking, the reporting party stated that the facility was made aware by the reporting party and the responsible party that the radiator in R1's room has been leaking but nothing was done.

As part of the investigation, LPA interviewed maintenance director and reviewed written communication correspondences.

During the initial complaint visit on 5/3/2023, LPA observed paper towels placed underneath the heater radiator due to leaks.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230427140227

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/31/2023

NARRATIVE

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The maintenance director acknowledged that the radiator has been leaking and the paper towel is placed to keep that area dry.

After the investigation, this allegation is substantiated.

Regarding to allegation of- facility placed a hazardous item next to resident's bed, the reporting party stated that facility provided a space heater in place of radiator for heat and it is placed next to R1's bed which could be a safety hazard.

As part of the investigation, LPA reviewed the Comfort Zone Compact Heater manufacture instruction for the space heater and interviewed the maintenance director.

According to the Comfort Zone Compact Heater instructions, one of the warning: fire hazard is do not use near combustible materials; keep combustible materials such as furniture, pillows bedding, papers, clothes and curtain at least 3 feet (0.9) from the front of the heater. However, during the initial complaint visit on 5/3/2023, LPA observed the Comfort Zone space heater was placed on top of a night stand that was next to R1's bed with a small gap in between the night stand and the bed.

In addition, the maintenance director stated the space heater was placed in R1's room to provide heat as the radiator was broken and the maintenance director acknowledged that it was placed too close to R1's which could be a safety hazard.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews, observations and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, and Appeal Rights provided.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230427140227

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/31/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/01/2023 Section Cited CCR 87307(d)(3)	1 2 3 4 5 6 7	87307 Personal Accommodations and Services..(d) The following space and safety provisions shall apply to all facilities:..(3) All persons shall be protected against hazards within the facility...	1 2 3 4 5 6 7	The administrator/licensee will conduct rounds to ensure facility is using devices following the manufacture instructions. In addition, the administrator/licensee will develop a plan to
	8 9 10 11 12 13 14	The requirement is not met as evidence by facility provided a space heater for R1 to replace the heater as the heater was malfunctioned and the space heater was observed next to resident's bed which posed an immediate health risk to resident in care.	8 9 10 11 12 13 14	prevent this from happening again and the plan shall include staff training. The administrator will submit the findings from the rounds and will submit a copy of the plan to CCL by 6/1/2023.
Type B 06/08/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation...(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by R1's window has	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure facility is in good repair at all times and when repair is needed, the work shall be completed in a timely manner or other alternative shall be offered in a timely manner.
	8 9 10 11 12 13 14	been broken since 2021 and the heater radiator has been broken for many months which posed a potential risk for resident in care.	8 9 10 11 12 13 14	The administrator will provide an estimated date of repair completion or an alternate plan to address the broken window by 6/8/2023. The administrator will submit a copy of the plan to CCL by 6/8/2023

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: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2023

LIC9099 (FAS) - (06/04)

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