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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 11/20/2020
Date Signed: 11/20/2020 12:30:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAGEBROOK SENIOR LIVING AT SAN FRANCISCOFACILITY NUMBER:
385600423
ADMINISTRATOR:ANGELA L BOUCHER-TURINFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 55DATE:
11/20/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrators, Angela Boucher-Turin and Tod MurrayTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Raygoza made an unannounced case management virtual visit and stated purpose of visit to Administrator, Tod Murray.

During the investigation of complaint 14-AS-20201029181101, information provided by the licensee indicates that a resident (R1) had a change of level of care and had become dependent on others to perform all activities of daily living. The information and documentation available indicate that upon admission, the resident was able to assist in activities of daily living, but within the last few months, the residents condition changed, becoming a three person assist, and unable to assist in ADL’s. Consequently, the care plan was changed from Regular showers to sponge baths. It was indicated also that the licensee had not requested an exception and had failed to obtain otherwise authorization to retain a resident with prohibited health conditions. It was also indicated that no provisions were made to have the resident transfer to a higher level of care facility. The facility is cited under Section 87615 (a) (5) Prohibited Health Conditions.



Cont'd on 809D.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 11/20/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020
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
CCLD Regional Office, 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: 11/20/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type A
11/21/2020
Section Cited

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87615 (a) (5) Prohibited Health Conditions. Persons who require health services for or have a health condition including, but not limited to, those residents who depend on others to perform all activities of daily living for them as set forth in Section 87459, Functional Capabilities.
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This requirement has not been met as evidenced by: the retention of a resident who became dependent on others to perform all activities of daily living. It was indicated also that the licensee had not requested an exception and obtain otherwise authorization to retain a resident with prohibited health conditions, which poses an immediate health, safety or personal rights risk to residents.
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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: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:
DATE: 11/20/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/20/2020
LIC809 (FAS) - (06/04)
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