<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385600423
Report Date: 11/20/2020
Date Signed: 11/24/2020 08:38:02 AM



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 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
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrators, Angela Boucher-Turin and Tod Murray TIME COMPLETED:
12:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Due to lack of staff resident did not receive showers
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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. Documentation received during the investigation indicates that the facility has suffered a shortage of staff within the last few months. Based on this information, preponderance of evidence indicates that at least one of the considerations taken to switch from regular showers to sponge baths was due to a reduction of staff. The allegation is substantiated.

The above allegation is found to be SUBSTANTIATED meaning that the allegation is valid because the preponderance of the evidence standard has been met.

This report was reviewed and discussed with the Administrator, Tod Murray.
Substantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
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: 11/20/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
11/21/2020
Section Cited
CCR
87411(a)
1
2
3
4
5
6
7
87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
1
2
3
4
5
6
7
Aministrator stated to develop a written plan of correction (POC) describing how facility shall ensure compliance with 87411(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 documentation reviewed, R1’s had his/her care plan changed from regular showers to sponge baths due to the facility lacking
sufficient staff to provide for a three-person assists accommodation which poses an immediate health, safety or personal rights risk to residents.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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
LIC9099 (FAS) - (06/04)
Page: 4 of 4