<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 12/15/2025
Date Signed: 12/15/2025 03:38:27 PM

Document Has Been Signed on 12/15/2025 03:38 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAGEBROOK SENIOR LIVING AT SAN FRANCISCOFACILITY NUMBER:
385600423
ADMINISTRATOR/
DIRECTOR:		PETER T. NIXDORFFFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY: 111CENSUS: 66DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Juvy Valera, Receptionist and Peter Nixdorff, Executive Director TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 12/15/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Juvy Valera, Receptionist and explained the purpose of the visit. Peter Nixdorff, Executive Director arrived later during the visit.

LPA toured the physical plant. This is a 3-story building with 78 bedrooms, 74 bathrooms, a kitchen, backyard, and common spaces. All bedrooms had the required furniture and sufficient lighting. All bathrooms had slip resistant flooring and grab bars. The facility was maintained at a comfortable temperature. No accessible bodies of water or hazards were observed. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's fire alarm and carbon monoxide detector were observed to be in working order. The facility's first aid kit had the required items.

All soap, sharp objects, and poisons were observed to be locked and in-accessible to persons in care.

LPA reviewed 5 resident files and 6 staff files. All were observed to be complete.

This facility does not handle cash resources.

LPA received copies of the following documents while at the facility:
  • Administrator's Certificate
  • Current LIC 500-staff roster and resident roster
  • Liability Insurance
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SAGEBROOK SENIOR LIVING AT SAN FRANCISCO
FACILITY NUMBER: 385600423
VISIT DATE: 12/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

In addition, per conversation with the Executive Director the facility has 1 staff member per shift that has active CPR and First Aid Training. During document review, LPA was not provided with documentation. A Type B citation was provided for this deficiency.

When LPA arrived at the facility to conduct the Annual Audit, LPA asked to review staff and resident records. LPA was told by S1 that no one at the facility currently could access said files. Two hours after the LPA arrived at the facility, files were made accessible. A Type B citation was provided for this deficiency.

Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties.

An exit interview was conducted. This report was reviewed with facility representative and a copy provided.
NAME OF LICENSING PROGRAM MANAGER: Brenda Chan
NAME OF LICENSING PROGRAM ANALYST: John Calandra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 12/15/2025 03:38 PM - It Cannot Be Edited


Created By: John Calandra On 12/15/2025 at 03:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.32
Regulations
Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not ensure that resident and personnel files were accessible and could be reviewed by the LPA for 2 hours, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
1
2
3
4
Licensee will get a second key and access code made to ensure that files are accessible to any duly authorized officer, employee, or agent.
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and record review, the licensee did not ensure they had documentation on file of one staff member who has CPR and first aid training on duty and on the premises at all times, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
1
2
3
4
Licensee will schedule someone to come in and train staff on CPR and First Aid training and send proof that 1 staff member per shift has active CPR and First Aid training.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Brenda Chan
NAME OF LICENSING PROGRAM MANAGER:
John Calandra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 3 of 4