385600423-1-8-2025-14-AS-DTOA-DCQVLW-20250108153237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 01/08/2025
Date Signed: 01/08/2025 03:36:44 PM

Document Has Been Signed on 01/08/2025 03:36 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 FRANCISCO		FACILITY NUMBER:	385600423
ADMINISTRATOR/ DIRECTOR:	PETER T. NIXDORFF		FACILITY TYPE:	740
ADDRESS:	2750 GEARY BLVD		TELEPHONE:	(415) 346-0246
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY: 111	TOTAL ENROLLED CHILDREN: 0	CENSUS: 62	DATE:	01/08/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:43 AM
MET WITH:	Peter Nixdorff, Executive Director		TIME VISIT/ INSPECTION COMPLETED:	03:00 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 1/8/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Peter Nixdorff. The facility currently provides care for 62 residents, 4 of which are receiving hospice services, along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor and kitchen were found to be last charged. Carbon monoxide detectors were located at each hallway tested and functioning. Smoke and sprinkler systems are interconnected with a fire safety inspection conducted by separate outside agency. Water at faucets accessible to residents were measured and found to be within regulation. All resident restrooms are equipped with non-slip mats and grab bars for accessibility. During the inspection, LPA observed oxygen tank in resident bedroom without appropriate signage posted. Executive Director immediately contacted staff to place sign indicating oxygen in use. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished three times per week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. During inspection of resident bedroom, LPA located a tool bag left by residents family that held items potentially dangerous to residents in care. Executive Director immediately contacted resident's family member notifying of the concern and placed the tool bag in a secured staff office. Executive Director agrees to further discuss with resident family on safety risks. Technical Violation issued. Continued onto LIC809-C

Andrea Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

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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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: 01/08/2025

NARRATIVE

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Residents that were awake during the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences. LPA found that staff and resident engagement is well practiced with activities observed throughout the day. Residents were observed to have a positive and personable relationship with staff and Executive Director and were often out in the community during the inspection. There is a large outdoor patio for resident use, equipped with appropriate shading.

A spot check of medications was conducted and found that all medication counts and records are in order. Medtech staff were knowledgeable of all medication administration and destruction procedures. LPA conducted a sample file review for residents and found all items to be in order including medical assessments and needs & service plans. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR on file.

Peter Nixdorff's Administrator Certificate 7014086740 is currently active through 1/26/2025.

LPA requested the following documents be sent to CCL by COB 1/22/2024:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

SUPERVISOR'S NAME: Andrea Medlin	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/08/2025 03:36 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: 01/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Oxygen Administration - Gas and Liquid

(3) Ensuring that the use of oxygen equipment meets the following requirements: (B) “No Smoking-Oxygen in Use” signs shall be posted in the appropriate areas. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in 1 oxygen use signage not posted on resident shared bedroom which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	Executive Director will provide photo proof of appropriate use of oxygen signeage on resident bedroom door by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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

Andrea Medlin	TELEPHONE: (650) 266-8811
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 01/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2025

LIC809 (FAS) - (06/04)

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