385600423-8-15-2023-14-AS-KHOS-CUWJ9W-20230821065145

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 08/15/2023
Date Signed: 08/15/2023 11:11:54 AM

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
08/08/2023 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230808165248

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: 60	DATE:	08/15/2023
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Sales Director David Estrada and administrator Fili Howard		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

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Staff did not repair resident's window.

INVESTIGATION FINDINGS:

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On August 15, 2023, Licensing Program Analysts (LPA) Murial Han and LPA John Calandra conducted an unannounced 10-day complaint inspection. LPAs met with Sales Director, David Estrada and explained the purpose of today's visit. The administrator and maintenance director arrived shortly thereafter and assisted with the rest of the inspection.

During today's visit, LPAs toured resident-in-question (R1)'s room, tested the bathroom window, interviewed administrator and maintenance director.

Regarding to allegation of - staff did not repair resident's window, during the initial reporting, the reporting party stated that R1's bathroom window is very hard to open and close and the reporting party is worried that R1 would get hurt while doing that.

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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-20230808165248

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: 08/15/2023

NARRATIVE

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During the tour of R1's room, LPAs attempted to open and close the bathroom window but it was very tight.

R1 attempted to open and close the window, however, R1 was not able to do so due to the tightness of the window.

The sales and marketing director was able to open and close the bathroom window but acknowledged that it took a lot of strength.

The administrator and the maintenance director were not aware of the bathroom window problem in R1's room, however, after attempting to open and close it, they acknowledged that it was tight, it took a lot of strength to operate it and it would be hard for R1 to open and close it.

The maintenance director spray WD-40 oil around the window frame to loosen it but it was not successful.

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230808165248

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: 08/15/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/18/2023 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 bathroom window is very hard to	1 2 3 4 5 6 7	The administrator will provide a repair completion date to CCL by 8/18/2023. Upon completion of the repair, the administrator will provide proof to CCL.
	8 9 10 11 12 13 14	open and close which poses a potential health risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC9099 (FAS) - (06/04)

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