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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 06/23/2021
Date Signed: 06/23/2021 12:57:12 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: 41DATE:
06/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Executive Director, Angela Boucher- TurinTIME COMPLETED:
01:05 PM
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On 6/ 23 /2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on two incident reports/ SOC 341 reports that were reported by the facility. LPA Han met with the Executive Director, Angela Boucher- Turin and explained the purpose of the visit.

The facility has reported two incidents involving resident to resident altercations during meal services in the dining room:

First Incident: on 6/5/2021, Resident 1 (R1) wanted additional cookies and attempted to grabbed Resident 2 (R2)'s cookies that caused R2 to stand-up from his table and when Resident 3 (R3) saw R2 stood up, he/she thought R2 was going to hurt R1 so he/she pushed R2 and R2 sustained some injuries.

Second Incident: on 6/13/2021, R1 was grabbing food from Resident 4 (R4) that caused R4 punching R1's face, stumbled backwards and fell. Staff reported that there was no injuries noted to both residents.

Since the first incident, the facility has increased supervision for R1, reviewed and updated R1's care plan, and provided one on one feeding assistance. Furthermore, the facility has consulted with their consulting group regarding R1's behaviors as R1 has never exhibited these behaviors in the past and the outcome was R1's behavior may be related to recent change in medication.

During the visit, LPA observed that there were three caregivers providing service and supervision during meal service in the dining room. R1 was assisted with feeding by one of the Medication Technicians and R1 observed to be restless and walked away from the sitting area several times while being assisted with feeding.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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
VISIT DATE: 06/23/2021
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LPA interviewed three caregivers regarding to supervision in the dining room during meal services and they reported that there are three caregivers assigned in the dining room during meal service. One of them would go back and forth to escort residents from their rooms to the dining room for their meals while the other two stay in the dining room providing supervision for the residents who are in the dining room. In addition, they stated that they have increased supervision and they are providing one to one meal service for R1 since the incident and there are no further incidents.

No deficiency is cited today.

This report is reviewed, discussed with the Executive Director, a copy is provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
LIC809 (FAS) - (06/04)
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