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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 01/11/2024
Date Signed: 01/11/2024 04:39:02 PM


Document Has Been Signed on 01/11/2024 04:39 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:FAIMAFILI HOWARDFACILITY TYPE:
740
ADDRESS:2750 GEARY BLVDTELEPHONE:
(415) 346-0246
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94118
CAPACITY:111CENSUS: 62DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Laura Richardson, Program DirectorTIME COMPLETED:
04:45 PM
NARRATIVE
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On January 11, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:04 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Laura Richardson, Program Director. Faimfili Howard, Executive Director arrived later and joined the visit.

LPA Calandra toured the physical plant. This is a 3-story building that consists of 79 rooms and 79 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on July 6, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources at this time. LPA Calandra received Consolidated Emergency Response/Contingency Plan and Floor plans.

All knives and sharp objects were observed to be locked and in-accessible to persons in care.

All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care.

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 kept at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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


Document Has Been Signed on 01/11/2024 04:39 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: 01/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)
CCR 87355(e)(2): Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, licensee failed to request a transfer of criminal record clearance for S1 and S2 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 and S2 are not associated to the facility on this day 1/11/2024.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 and S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. An immediate civil penalty of $100 a day for the period of 1/6-1/11/2024 was assessed on this day.

Type A
Section Cited
CCR
87355(e)(1)
CCR 87355(e) Criminal Record Clearance: All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance or a criminal record exemption as required by the Department.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records review, licensee failed to obtain a criminal record clearance for S1 which poses an immediate health and safety risk to clients in care. It is confirmed that S1 does not have a criminal record clearance on this day 1/11/2024.
POC Due Date: 01/12/2024
Plan of Correction
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Administrator shall ensure to submit proof of fingerprinting of S2 and proof of clearance to the licensing office for S2 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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 SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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: 01/11/2024
NARRATIVE
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LPA Calandra requested the following documents from the facility be sent via email or fax to the RO:

-Job description/Personnel policies/on-the-job training
-Fire Clearance
-Health Screening Reports-Facility Personnel(LIC 503)
-Plan of Operation
-Plan for Incidental Medical and Dental Care
-Qualifications of Administrator-Admin Certificate
-Affidavit Regarding Client/Resident Cash Resources (LIC 400)

During the tour of the physical plant, LPA observed S1 sitting on a bench in the hallway of Assisted Living, Floor 2. LPA asked staff member, their name, and S1 stated their name. LPA checked Facility Personnel Summary Report and could not find a staff member listed with that name. During a tour of the Assisted Living dining room, LPA stopped and spoke with S2 and asked S2 their name. S2 stated their name and LPA looked at the Facility Personnel Summary Report but again could not find anyone listed. LPA then called the RO and asked support staff to look up both staff. Support staff could not find S1 associated to the facility and S2 does not have criminal record/fingerprint clearance. LPA spoke to Executive Director about S1 and S2 and explained that until S2 has fingerprint/criminal record clearance, they cannot work. LPA explained that civil penalties would be assessed for both deficiencies.



SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 3 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: 01/11/2024
NARRATIVE
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During today's visit a Civil Penalty of $1,000 was assessed for failure to ensure all individuals subject to a criminal record review were approved for a transfer of a criminal record exemption, as specified in Section 87355 and failure to obtain a California clearance or a criminal record exemption as required by the Department. Civil Penalty is $100 a day per staff member (2x) for the period of 1/6/2024-1/11/2024.

The Annual will be completed at a later date.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

The report was reviewed with Executive Director, Fili Howard and a copy along with Appeal rights were left at the facility.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4