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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 07/28/2021
Date Signed: 07/30/2021 05:38:40 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: 46DATE:
07/28/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Angela Boucher TuninTIME COMPLETED:
01:40 PM
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On 07/28/21, Licensing Program Analyst (LPA), Mohamed Filouane, conducted a Case Management visit at the facility with Executive Director (ED) Angela Boucher Tunin, regarding an Incident Report received by the Community Care Licensing Division on 7/27/21. The incident involves a female resident (R1) and a male caregiver (C1). LPA Filouane reviewed the information reported on the Incident Report.

The facility's investigation is currently ongoing. In an interview with the ED, LPA Filouane clarified the information reported on the Incident Report. The incident occurred on 07/26/21, when another caregiver (C2) had entered the Memory Care unit of the facility. It is reported in the Incident Report and in an interview with the ED that C2 opened the restroom door and witnessed C1 with their back turned, hands raised, and their trousers down to their knees with their underpants still raised, standing close towards R1. R1 was leaning against the restroom sink with their hands on their side. R1 wore only a bathrobe. It is reported that after C2 witnessed that C1 was undressed with a resident, C2 had went to inform a Medical Technician on duty. The Medical Technician then arrived at the restroom in the Memory Care unit and witnessed the resident unclothed and C1 showering the resident. The Medical Technician reported the incident to the Executive Director, who instructed C1 to leave the facility pending investigation.

The Executive Director states that on the same day of 07/26/21, after the ED had instructed C1 to leave the facility, C1 was found in a resident's closed room with R1 and another resident. The Executive Director made their way to the room and estimates that C1 was in the room with R1 and another resident for less ten minutes. According to the ED, the ED asked what C1 was doing in the room, and C1 stated they were telling R1 that they were leaving.

San Francisco Police Department arrived at the facility on 07/26/21 and interviewed the resident. Facility management interviewed the caregiver and Medical Technician. LPA requested physician reports of two residents, documentation of facility interviews with staff members, and will contact SFPD for the police report and R1's hospital visit results.

Exit interview conducted with Executive Director. This report will be emailed to the Executive Director.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 07/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021
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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