385600423-11-25-2020-14-AS-KHOS-BZLHFY-20210330061016

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 11/25/2020
Date Signed: 11/25/2020 04:29:48 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/29/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201029181101

FACILITY NAME:	SAGEBROOK SENIOR LIVING AT SAN FRANCISCO		FACILITY NUMBER:	385600423
ADMINISTRATOR:	ANGELA L BOUCHER-TURIN		FACILITY TYPE:	740
ADDRESS:	2750 GEARY BLVD		TELEPHONE:	(415) 346-0246
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94118
CAPACITY:	111	CENSUS: 45	DATE:	11/25/2020
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Tod Murray and Angela Boucher-Turin, Administrators		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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- Resident at risk of infection has not received showers for months
- Resident did not receive safe healthful accommodations

INVESTIGATION FINDINGS:

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==============THIS IS AN AMENDMENT =====================

Licensing Program Analyst (LPA) Raygoza conducted an unannounced virtual visit via Facetime and stated purpose of visit to Administrators, Angela Boucher-Turin and Tod Murray. The information available to the department indicates that the resident has not received showers since June 2020, and has received sponge baths instead.

- Resident at risk of infection has not received showers for months
Based on five out of five interviews and records review of Needs and Services Plan, the facility did not ensure to provide R1 with regular showers. Facility did not ensure to provide R1 with Basic Services. R1 was given sporadic showers and sponge baths in lieu of showers. Therefore the allegation is SUBSTANTIATED.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20201029181101

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 11/25/2020

NARRATIVE

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THIS IS AN AMENDMENT - CONT'D 9099

- Resident did not receive safe healthful accommodations
Based on three out of three interviews and record review of Needs and Services Plan, R1 cannot assist with activities of daily living (ADL's) and R1's level of care has changed. Based on record review of Needs and Services Plan, R1 is incontinent. Upon Record review, R1 is three person assist and was provided with sponge baths in lieu of showers. Based on Interviews, showers are done sporadic for R1 and facility did not ensure to provide R1 with regular showers depending on staff availability. Therefore, the allegation was SUBSTANTIATED.

The above allegations are found to be SUBSTANTIATED, meaning that the allegations are valid because the preponderance of the evidence standard has been met.

This report was reviewed and discussed with Administrator, Angela Boucher-Turin. .

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20201029181101

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/25/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 11/27/2020 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464(f)(1) Basic Services - Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).	1 2 3 4 5 6 7	Administrator stated will develop and submit a (POC) plan of correction to ensure that facility is able to provide proper Basic services 87464(a). POC to be submitted by due date.
	8 9 10 11 12 13 14	This requirement was not as evidenced by: Based on records reviews and interviews, licensee did not ensure to provide Basic Services which includes regular showers for R1 which poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type A 11/27/2020 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	87468.1(a)(2) Personal Rights of Residents in All Facilities - Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment which poses an immediate health, safety or personal rights risk to residents.	1 2 3 4 5 6 7	Aministrator stated to develop a written plan of correction (POC) describing how facility shall ensure compliance with 87468(a). POC to be submitted by due date.
	8 9 10 11 12 13 14	This requirement has not been met as evidenced by: Based on staff interviews and records review of Needs and Services Plan, R1 did not receive healthful accommodations. Resident cannot assist with ADL’s. Licensee did not ensure to provide R1 with regular showers which poses an immediate health, safety or personal rights risk to residents in care.	8 9 10 11 12 13 14

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 Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2020

LIC9099 (FAS) - (06/04)

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