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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 389210022
Report Date: 06/20/2023
Date Signed: 06/20/2023 12:13:57 PM

Document Has Been Signed on 06/20/2023 12:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:BRODERICK STREET ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
389210022
ADMINISTRATOR:KRISTIN CHUNFACILITY TYPE:
735
ADDRESS:1421 BRODERICK STREETTELEPHONE:
(415) 292-1760
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94115
CAPACITY: 33CENSUS: 28DATE:
06/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Kristin ChunTIME COMPLETED:
12:25 PM
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On 6/20/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow up on the incidents that the facility has reported to CCL. LPA met with the administrator and explained the purpose of the visit.

On 6/5/2023, facility reported resident #1 (R1) hit resident #2 (R2) and subsequently hit resident #3 (R3). R2 did not sustained any injuries; R3 sustained injuries and was sent to the hospital and returned on the same day.

On 6/19/2023, facility reported R1 hit resident #4 (R4) and both residents were assessed after the incident and no injuries were noted.

After the incidents, facility conducted assessments for all residents involved, transferred R1 to the hospital for further assessment/evaluation, provided half hourly and hourly rounds to check on R1, updated R1's service needs/plan, notified resident's responsible parties, local law enforcement, Community Care Licensing, Adult Protective Services (APS), Ombudsman and attending physicians.

During today's visit, LPA interviewed the administrator, reviewed documents provided by the facility and observed residents involved.

According to the administrator, since R1's return from the hospital, there was no new incidents between R1 and other residents. In addition, the facility has implemented the following actions to prevent any incidents from happening again: staff continued to provided frequent rounds to check on R1 as indicated on the updated service needs/plan, facility has made arrangements for R1 to be in a private room, staff provides supervision whenever R1 leaves the room to ensure safety and work with San Francisco Department of Public Health on discharge planning.


SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/20/2023
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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: BRODERICK STREET ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 389210022
VISIT DATE: 06/20/2023
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During the facility tour, LPA observed R1 in a private room, appeared to be calm and staff brought R1 coffee. LPA observed R2 who was leaving the facility and stated, " I am doing fine and I am going out now". LPA observed R3 in the dining room and stated, "I am doing fine". LPA observed R4 reading newspaper by the front entrance.

No deficiency cited today.

This report is reviewed and discussed with administrator; a copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2023
LIC809 (FAS) - (06/04)
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