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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385600423
Report Date: 08/23/2021
Date Signed: 08/23/2021 01:02:34 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: 56DATE:
08/23/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:The Executive Director, Fili HowardTIME COMPLETED:
01:15 PM
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On 8/23/2021, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to follow-up on an incident reports/ SOC 341 that was reported by the facility. LPA Han met with the Executive Director, Fili Howard and explained the purpose of the visit.

The incident happened 8/17/2021 around breakfast time, when the Medication Technician who was preparing medication in the dining room, he/she heard a loud and witnessed that R1's right arm was extended upward in a swinging motion and R2 was on the floor. The staff reported that R2 has a tendency of grabbing other resident's foods and R1 was trying to stop R2 from grabbing R3's food.

During the visit, LPA interviewed the Executive Director, the staff members who were in the dining room during the incident, and the residents who were involved in the incident. In addition, LPA observed the dining room area and requested for additional documentation for the residents who were involved.

This incident requires further investigation.

This report was reviewed and discussed with the Executive Director and a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2021
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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