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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:23:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250113143203
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: DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Peter Nixdorff, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident sustained multiple injuries due to neglect/lack of supervision
INVESTIGATION FINDINGS:
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On 4/10/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Peter Nixdorff. LPA toured the facility, interviewed staff and outside parties and reviewed resident records during the course of the investigation.

Complaint alleges resident sustained multiple injuries due to neglect/lack of supervision. Based upon review of R1’s records it is determined that R1 had sustained three separate incidents in which R1 had been involved in multiple unwitnessed falls. The facility completed an updated care appraisal, implementing an increased level of care for more frequent room checks, staff escort to activities and common spaces, transferring from sitting to standing and use of a walker due to the identified high fall risk, confusion and diagnoses of Parkinson's and major neurocognitive disorder. Facility however, failed to update R1's medical assessment corresponding to R1's updated needs.

Interviews with staff further indicated that staff were notified and aware of R1's high fall risk and changes of condition, However staff stated being busy and not present during R1's unwitnessed fall located in facility common area leading to fracture of R1's hip and wrist. LPA found that staff did not provide appropriate care and supervision according to R1's care appraisal resulting in injury.

Continued onto LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/13/2025 and conducted by Evaluator Dominic Tobola
COMPLAINT CONTROL NUMBER: 14-AS-20250113143203

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: DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Peter Nixdorff, Executive DirectorTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Resident was not properly assessed and placed upon admission
INVESTIGATION FINDINGS:
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On 4/10/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Peter Nixdorff. LPA toured the facility, interviewed staff and outside parties and reviewed resident records during the course of the investigation.

Complaint alleges resident was not properly assessed and placed upon admission. Upon review of R1’s physician’s report, pre-admissions appraisal and level of care appraisal, although R1 had a diagnosis of major nueurocognitive disorder and Parkinson's, there were no indications of R1’s activities of daily living or capabilities that clearly determined R1 to be placed in memory care specific program from admission. At the time of admission, R1 with was deemed by their physician along with the facility assessment to be capable of ambulating independently and able to communicate needs. In addition, LPA interviewed R1’s responsible party who indicated information contradicting to allegation. Due to a lack of corroborating evidence and conflicting information gathered, the allegation is found to be unsubstantiated.
A finding that the complaint allegations, facility staff are locking residents in their bedrooms
& facility staff are not conducting planned activities with residents are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. No deficiency cited.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20250113143203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/10/2025
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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Licensee/administrator shall submit a plan in writing on how to ensure staff provide proper care and supervision to all residents. Plan must include training, staffing, observation of resident, addressing changes in condition. Plan shall be submitted to CCLD by 4/11/25.
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facility incident reports, resident records and interviews with staff the facility failed to ensure staff had provided necessary services of care and supervision to meet resident R1's resutling in injury to R1.
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An immediate Civil Penalty of $250 was assessed for repeated violations within a 12-month period.
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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: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20250113143203
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/10/2025
NARRATIVE
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Allegation, above is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Civil Penalty was assessed for incident resulting in injury of resident.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4