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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 09/13/2024
Date Signed: 09/13/2024 01:34:42 PM


Document Has Been Signed on 09/13/2024 01:34 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:PETER T. NIXDORFFFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 54DATE:
09/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Peter Nixdorff, Program DirectorTIME COMPLETED:
01:45 PM
NARRATIVE
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On 9/13/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on a facility reported incident and met with Program Director Peter Nixdorff. The incident occurred on 8/25/2024 involving resident (R1) eloping from the facility without supervision. R1 had been observed in the facility common area the previous evening on 8/24/2024. During morning medication pass, staff did not observe R1 in their bedroom. Program Director immediately notified local police department, R1's responsible party and Community Care Licensing. R1 was located at a nearby medical center and found to have no injuries or significant changes of condition. Upon review of records, it is found that R1 is unable to leave the facility unassisted.

The facility has updated R1's level of care including more frequent room checks, updated R1's physician's report and will be meeting with R1's responsible party for revised needs & service plans. In addition the facility has implemented front door security with secured door hours from 4pm - 8am, and utilizing overnight front desk attendance. R1 has not demonstrated any further behaviors of exit seeking and the facility has implemented appropriate measures to ensure no further incidents occur.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2024 01:34 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2024
Section Cited
CCR
87464(f)(1)

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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c). This was not met as evidence by**: Based upon facility incident report, interviews with staff and a review of
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The facility has implemented multiple preventative measures to increase monitoring for R1, secure exit parameters for safety during evening hours and update R1's level of care and documentation. The facility continues to monitor R1 for additional changes. LPA finds that the faciltiy has
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resident records, it was found that R1 had AWOL from the facility without staff supervision. This serves a potential health & safety risk to resident in care.
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responded appropriately for corrections. Deficiency cleared at the time of visit.

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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
LIC809 (FAS) - (06/04)
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