Inspection Reports for Sagebrook Senior Living
2750 Geary Blvd, San Francisco, CA 94118, United States, CA, 94118
Back to Facility ProfileInspection Report Summary
Most inspections found deficiencies related to resident care and supervision, facility maintenance, and regulatory compliance, with several substantiated complaints over the past few years. The facility received civil penalties, including a $250 fine in April 2025 for failure to provide adequate supervision that resulted in resident injury, and earlier fines related to criminal record clearance lapses and care deficiencies. Issues with safety hazards such as broken windows, improperly placed space heaters, and missing oxygen signage were also noted, though many were addressed promptly. Several complaint investigations were unsubstantiated, including concerns about food service and staff responsiveness. The most recent report from September 24, 2025, was clean with no deficiencies, indicating some improvement in compliance and oversight.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
58% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 64
Capacity: 111
Deficiencies: 0
Date: Sep 24, 2025
Visit Reason
The visit was conducted as a Case Management visit in response to an incident report received regarding a resident who eloped while in the community.
Complaint Details
The visit was triggered by an incident report received on 2025-09-19 concerning a resident who eloped while in the community. The resident was not located at the time of the inspection. No deficiencies were cited.
Findings
The Licensing Program Analyst toured the facility and found all exit doors and door alarms fully operational. Interviews revealed the resident eloped during a medical appointment under supervision. The resident had not been found at the time of the visit. No deficiencies were cited.
Report Facts
Capacity: 111
Census: 64
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the case management visit and inspection |
| Peter T. Nixdorff | Executive Director | Facility representative who met with the Licensing Program Analyst and was involved in the incident response |
Inspection Report
Follow-Up
Capacity: 111
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The visit was an unannounced follow-up inspection to investigate a reported incident involving a resident leaving the facility unassisted.
Findings
The facility responded appropriately to the incident by implementing in-service training, updating signage, and holding care conferences. The resident was safely returned with no injuries and has since relocated. A technical violation was issued during the visit.
Deficiencies (1)
Technical violation issued related to resident leaving the facility unassisted.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and investigation of the incident. |
| Peter T. Nixdorff | Executive Director | Facility administrator involved in implementing corrective actions. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 1
Date: Apr 10, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted due to allegations that a resident sustained multiple injuries due to neglect and lack of supervision, and that a resident was not properly assessed and placed upon admission.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident sustained multiple injuries due to neglect and lack of supervision. The allegation that a resident was not properly assessed and placed upon admission was unsubstantiated. Staff failed to provide proper care and supervision leading to injury. A civil penalty was assessed.
Findings
The complaint that a resident sustained multiple injuries due to neglect and lack of supervision was substantiated, with findings that staff failed to provide appropriate care and supervision resulting in injury. The allegation that a resident was not properly assessed and placed upon admission was found to be unsubstantiated due to lack of corroborating evidence. A civil penalty of $250 was assessed for repeated violations within a 12-month period.
Deficiencies (1)
Failure to provide necessary care and supervision to meet resident R1's needs resulting in injury, violating CCR 87464(f)(1) and Health and Safety Code section 1569.2(c).
Report Facts
Civil Penalty: 250
Capacity: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and authored the report. |
| Andrea Medlin | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
| Peter T. Nixdorff | Executive Director | Facility representative met during the investigation. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 111
Deficiencies: 1
Date: Jan 8, 2025
Visit Reason
An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with regulatory standards.
Findings
The facility was found to be clean, well-maintained, and compliant with most regulations, including proper food storage, medication management, and staff certifications. One technical violation was issued for oxygen use signage not posted in a resident's shared bedroom, and a tool bag with potentially dangerous items was secured and addressed with the resident's family.
Deficiencies (1)
Oxygen use signage not posted on resident shared bedroom which poses a potential health, safety or personal rights risk to persons in care.
Report Facts
Residents receiving hospice services: 4
POC Due Date: Jan 15, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter T. Nixdorff | Executive Director | Met with Licensing Program Analyst during inspection and involved in addressing deficiencies |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection and authored the report |
| Andrea Medlin | Licensing Program Manager | Supervisor for the inspection |
Inspection Report
Complaint Investigation
Census: 62
Capacity: 111
Deficiencies: 0
Date: Jan 8, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not maintain a comfortable temperature for residents and that the facility was in disrepair due to heating system damage.
Complaint Details
The complaint alleged that staff did not maintain a comfortable temperature for residents and that the facility was in disrepair after heating system damage. The complaint was found to be unsubstantiated.
Findings
The investigation found that although the heating system was damaged affecting some bedrooms, the facility provided additional blankets and space heaters, and the affected rooms were warm and comfortable. The facility was still undergoing repairs but responded appropriately and timely. The allegations were found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 111
Census: 62
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Peter T. Nixdorff | Executive Director | Facility representative met during investigation |
| Andrea Medlin | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 54
Capacity: 111
Deficiencies: 1
Date: Sep 13, 2024
Visit Reason
The unannounced visit was conducted to follow up on a facility reported incident involving a resident eloping from the facility without supervision.
Findings
The facility was found to have an incident where a resident left without supervision, posing a potential health and safety risk. The facility responded by updating the resident's care plan, increasing supervision, and implementing front door security measures. The cited deficiency was cleared at the time of the visit.
Deficiencies (1)
Failure to provide adequate care and supervision as evidenced by a resident eloping from the facility without staff supervision.
Report Facts
Deficiency cited: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter T. Nixdorff | Program Director | Met with Licensing Program Analyst during the inspection and involved in incident response |
| Dominic Tobola | Licensing Program Analyst | Conducted the unannounced follow-up inspection |
| Andrea Medlin | Licensing Program Manager | Supervisor overseeing the inspection and deficiency citation |
Inspection Report
Complaint Investigation
Capacity: 111
Deficiencies: 0
Date: Sep 13, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to allegations received on 07/31/2024 regarding lack of supervision and absence of an active administrator on site at Sagebrook Senior Living at San Francisco.
Complaint Details
The complaint included allegations of lack of supervision, such as residents being left unattended in the lunch hall and a resident slipping out of a wheelchair, and that the facility did not have an active administrator on site. The lack of supervision allegation was unsubstantiated, and the administrator allegation was unfounded.
Findings
The investigation found the allegation of lack of supervision unsubstantiated after interviews with staff, residents, and directors indicated adequate supervision and responsive staff. The allegation that the facility lacked an active administrator was deemed unfounded as the facility had interim administrators and a certified administrator on site during the investigation.
Report Facts
Capacity: 111
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Peter Nixdorff | Program Director / Executive Director | Met with Licensing Program Analyst during investigation and discussed findings |
| Phoebie Carcot | Administrator | Named as facility administrator in report header |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Medlin | Licensing Program Manager | Reviewed and signed the report |
Inspection Report
Census: 62
Capacity: 111
Deficiencies: 0
Date: Feb 23, 2024
Visit Reason
The inspection was a case management health and safety inspection conducted by the Licensing Program Analyst to assess the facility's compliance and overall condition.
Findings
The facility was found to have sufficient perishable and non-perishable supplies, and the community was observed to be in good physical condition. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the case management health and safety inspection. |
| Jennine Chan | Assistant Executive Director | Met with the Licensing Program Analyst during the inspection and reviewed the report. |
| Stephanie Hall | Executive Director | Spoke with the Licensing Program Analyst via phone during the inspection. |
Inspection Report
Annual Inspection
Census: 64
Capacity: 111
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The inspection visit was conducted to continue the Annual 1-year required inspection of the facility.
Findings
No deficiencies were cited during the visit. Resident and staff records were reviewed and found to be complete.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faimafili Igafo | Executive Director | Met with during the inspection and reviewed the report. |
| John Calandra | Licensing Program Analyst | Conducted the inspection and reviewed records. |
Inspection Report
Plan of Correction
Capacity: 111
Deficiencies: 0
Date: Jan 31, 2024
Visit Reason
The visit was conducted to perform a Plan of Correction (POC) inspection at the facility.
Findings
No deficiencies were cited during the Plan of Correction visit. The report and POC clearance letter were reviewed with the Executive Director and a copy was left at the facility.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the Plan of Correction visit. |
| Fili Igafo | Executive Director | Met with Licensing Program Analyst during the visit. |
Inspection Report
Annual Inspection
Census: 62
Capacity: 111
Deficiencies: 2
Date: Jan 11, 2024
Visit Reason
The inspection was an unannounced Annual 1-year required inspection conducted to evaluate compliance with licensing regulations.
Findings
The facility was generally compliant with physical plant and safety requirements; however, deficiencies were found related to failure to obtain and transfer criminal record clearances for two individuals (S1 and S2), posing immediate health and safety risks. Civil penalties were assessed for these violations.
Deficiencies (2)
Licensee failed to request a transfer of criminal record clearance for S1 and S2, posing an immediate health and safety risk.
Licensee failed to obtain a criminal record clearance for S1, posing an immediate health and safety risk.
Report Facts
Civil penalty amount: 1000
Civil penalty daily rate: 100
Number of staff with clearance issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Faimafili Howard | Executive Director | Facility Executive Director present during inspection and discussed deficiencies. |
| Laura Richardson | Program Director | Met with Licensing Program Analyst during inspection. |
| Cara Smith | Licensing Program Manager | Supervisor of Licensing Program Analyst and named in report. |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 111
Deficiencies: 1
Date: Aug 15, 2023
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that staff did not repair a resident's bathroom window which was very hard to open and close, posing a potential safety risk.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. The allegation was that staff did not repair the resident's bathroom window which was difficult to open and close, posing a risk of injury.
Findings
The investigation found that the bathroom window in the resident's room was indeed very tight and difficult to operate, confirming the allegation. The maintenance director attempted to loosen the window with WD-40 oil but was unsuccessful. The deficiency was substantiated and cited under California Code of Regulations, Title 22.
Deficiencies (1)
R1's bathroom window is very hard to open and close which poses a potential health risk to resident in care.
Report Facts
Capacity: 111
Census: 60
Deficiency Plan of Correction Due Date: Aug 18, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| David Estrada | Sales Director | Met with LPAs during inspection and acknowledged window difficulty |
| Fili Howard | Administrator | Met with LPAs during inspection and acknowledged window difficulty |
| Cara Smith | Licensing Program Manager | Named in report and responsible for oversight |
Inspection Report
Complaint Investigation
Census: 59
Capacity: 111
Deficiencies: 2
Date: May 31, 2023
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2023-04-27 regarding facility maintenance and safety concerns.
Complaint Details
The complaint was substantiated based on interviews, observations, and record reviews. Allegations included failure to repair resident's window, leaking radiator heater, and hazardous placement of a space heater next to resident's bed.
Findings
The investigation substantiated that the resident's window had been broken since 2021 and was not repaired timely, the radiator heater in the resident's room was leaking, and a space heater was placed too close to the resident's bed posing a safety hazard.
Deficiencies (2)
Facility provided a space heater next to resident's bed which posed an immediate health risk.
Resident's window has been broken since 2021 and radiator heater leaking for many months, posing potential risk.
Report Facts
Facility capacity: 111
Census: 59
Deficiency Type A POC due date: Jun 1, 2023
Deficiency Type B POC due date: Jun 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Oversaw the complaint investigation |
| Fili Howard | Administrator | Facility administrator involved in investigation and discussions |
Inspection Report
Complaint Investigation
Census: 61
Capacity: 111
Deficiencies: 0
Date: May 24, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations regarding inadequate food service, failure of facility staff to meet residents' needs, and mismanagement of resident's medication.
Complaint Details
The complaint investigation was unsubstantiated as the allegations of inadequate food service, failure to meet residents' needs, and medication mismanagement could not be proven.
Findings
The investigation included multiple interviews, review of complaint documents, and photos. The allegations could not be proved or disproved, and the Licensing Program Analyst could not meet the preponderance of evidence standard to substantiate the claims. The allegations were determined to be unsubstantiated and no citations were issued.
Report Facts
Capacity: 111
Census: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation |
| Jennine Chan | Health and Wellness Director | Met with the Licensing Program Analyst during the investigation |
| Cara Smith | Licensing Program Manager | Named in report signature section |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 111
Deficiencies: 0
Date: May 3, 2023
Visit Reason
An unannounced case management visit was conducted to follow up on an incident reported by the facility involving a resident who was found unresponsive and later pronounced deceased.
Complaint Details
The visit was triggered by a reported incident where resident #1 was found unresponsive by a caregiver and later pronounced deceased by 911 responders. The facility reported the incident and submitted related documentation.
Findings
The visit involved reviewing documentation related to the incident; no deficiencies were cited during this inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced case management visit |
| David Estrada | Sales Director | Met with Licensing Program Analyst during the visit |
| Faimafili Howard | Administrator | Named as facility administrator |
Inspection Report
Complaint Investigation
Census: 67
Capacity: 111
Deficiencies: 0
Date: May 3, 2023
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation following a complaint alleging that staff illegally evicted a resident.
Complaint Details
The complaint alleged that staff illegally evicted a resident. The allegation was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Findings
The investigation found the allegation to be unfounded after interviews with the facility administrator and the resident's case manager, confirming that the resident was discharged per the resident's directive and with proper arrangements.
Report Facts
Facility capacity: 111
Census: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and unannounced visit |
| David Estrada | Sales Director | Met with Licensing Program Analyst during the investigation |
| Faimafili Howard | Administrator | Interviewed regarding the eviction allegation |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 111
Deficiencies: 0
Date: Mar 15, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility failed to provide adequate food service.
Complaint Details
The complaint alleged inadequate food service, including serving bad hamburger and uncooked hot dogs, and failure to provide requested foods and snacks. The allegation was unsubstantiated after investigation.
Findings
The investigation found the allegation unsubstantiated based on observations, interviews, and record reviews. Although some food items were not served as ordered to one resident, the facility staff took corrective actions and implemented a new system to improve meal accuracy.
Report Facts
Complaint Control Number: 14
Capacity: 111
Census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation visit |
| David Estrada | Sales Director | Met with Licensing Program Analyst during investigation |
| Faimafili Howard | Administrator | Interviewed regarding the food service allegation |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 56
Capacity: 111
Deficiencies: 0
Date: Jan 5, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control practices.
Findings
The facility was found to be clean, tidy, and compliant with infection control protocols including COVID-19 screening and signage. No accessible fire or water hazards were observed, and medication rooms were secured when unattended. No deficiencies were cited during this inspection.
Report Facts
Document submission deadline: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennine Chan | Resident Care Director | Met with during inspection and discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted the inspection and authored the report |
| Cara Smith | Licensing Program Manager | Named in report header and narrative |
Inspection Report
Follow-Up
Census: 56
Capacity: 111
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The visit was an unannounced follow-up to deliver the outcome from a case management visit on 6/20/22 concerning an incident reported by the facility on June 3, 2022.
Findings
Based on document review and interviews, no deficiencies were cited related to the incident involving resident #1 delivering mail to resident #2 and subsequently leaving the facility unassisted.
Report Facts
Facility capacity: 111
Resident census: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced follow-up visit and authored the report |
| Fili Howard | Administrator | Facility administrator met during the visit and discussed the report |
Inspection Report
Complaint Investigation
Census: 71
Capacity: 111
Deficiencies: 0
Date: Jun 20, 2022
Visit Reason
The visit was a case management incident investigation conducted regarding an unusual incident reported to the Community Care Licensing (CCL) involving a resident who left the facility and was witnessed performing unusual activity outside, triggering a 911 call.
Complaint Details
The visit was triggered by a complaint incident report (LIC624) received on June 3, 2022, regarding resident #1's unusual behavior outside the facility. The complaint was investigated through interviews and document review; substantiation status is not stated.
Findings
The Licensing Program Analyst met with the administrator, reviewed documents, and confirmed the incident involving resident #1. Additional care plans and medical records were to be provided for further follow-up. The incident requires further follow-up.
Report Facts
Capacity: 111
Census: 71
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faimafili Howard | Administrator | Met with Licensing Program Analyst during the visit |
| Murial Han | Licensing Program Analyst | Conducted the case management visit |
| Julio Montes | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 60
Capacity: 111
Deficiencies: 0
Date: Nov 3, 2021
Visit Reason
The visit was an unannounced follow-up to deliver the investigation outcome concerning an incident reported on 2021-09-20 involving an alleged staff action toward a resident.
Complaint Details
The complaint involved an allegation that Staff #2 strongly pulled Resident #1's ponytail in the dining room. The allegation was investigated and found to be unsubstantiated.
Findings
The facility investigated the allegation that Staff #2 pulled Resident #1's ponytail but determined the allegation to be unsubstantiated. No deficiencies were cited, and the facility provided an in-service to staff on Elder Abuse Reporting as a preventive measure.
Report Facts
Date of incident report: Sep 20, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Fili Howard | Administrator | Met with during the visit and interviewed regarding the facility's investigation process |
| Murial Han | Licensing Program Analyst | Conducted the investigation and follow-up visit |
| Julio Montes | Licensing Program Manager | Named in the report header |
Inspection Report
Complaint Investigation
Census: 60
Capacity: 111
Deficiencies: 1
Date: Nov 3, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 09/14/2021 regarding staff responsiveness, facility repair, safeguarding resident belongings, safe accommodations, and respect for resident privacy.
Complaint Details
The complaint investigation was based on allegations including staff not responding to resident calls, facility disrepair, failure to safeguard resident belongings, unsafe accommodations, and lack of respect for resident privacy. The allegation regarding safeguarding resident belongings was substantiated, while others were unsubstantiated or unfounded.
Findings
The investigation found most allegations to be unsubstantiated or unfounded, including staff responsiveness, facility repair, safe accommodations, and respect for resident privacy. However, the allegation that the facility did not safeguard a resident's personal belongings was substantiated due to staff washing a dry clean only duvet in a regular washer, damaging it.
Deficiencies (1)
Facility proceeded to put a dry clean duvet in a regular washer which posed potential health and safety risks to resident in care.
Report Facts
Capacity: 111
Census: 60
Plan of Correction Due Date: Nov 24, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Julio Montes | Licensing Program Manager | Reviewed and discussed the report with the Administrator |
| Angela L Boucher-Turin | Administrator | Facility Administrator involved in the investigation |
| Fili Howard | Administrator | Met with Licensing Program Analyst during the visit |
Inspection Report
Follow-Up
Census: 60
Capacity: 111
Deficiencies: 1
Date: Nov 3, 2021
Visit Reason
The visit was a follow-up case management inspection to deliver findings of an investigation regarding inappropriate contact between a staff member and a resident reported on 7/27/2021.
Complaint Details
The visit was complaint-related following a report that a caregiver engaged in inappropriate contact with a resident. The staff member denied sexual contact but acknowledged an emotional relationship. The resident was unable to consent. The complaint was substantiated based on preponderance of evidence.
Findings
The investigation found preponderance of evidence that a staff member engaged in inimical behavior and inappropriate contact with a resident, violating the resident's personal rights. The staff member was removed from the facility.
Deficiencies (1)
Persons prohibited from being a licensee or employee who engaged in conduct inimical to the health, morals, welfare, or safety of individuals in care.
Report Facts
Capacity: 111
Census: 60
Deficiency count: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Faimafili Howard | Administrator | Facility administrator met during the visit |
| Murial Han | Licensing Program Analyst | Conducted follow-up investigation and inspection |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 111
Deficiencies: 0
Date: Sep 22, 2021
Visit Reason
The visit was an unannounced follow-up on an incident report regarding an allegation that a staff member pulled a resident's ponytail.
Complaint Details
The complaint involved Staff 1 alleging that Staff 2 strongly pulled Resident 1's ponytail in the dining room. No injuries were noted upon assessment.
Findings
The Clinical Director conducted a skin assessment and found no injuries. The Licensing Program Analyst interviewed staff, observed the resident, and requested documents. The incident requires further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeannine Chan | Clinical Director | Met with Licensing Program Analyst during the visit and conducted skin assessment of the resident. |
| Murial Han | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 59
Capacity: 111
Deficiencies: 0
Date: Sep 14, 2021
Visit Reason
The visit was an unannounced Case Management visit to deliver findings from a prior visit on 2021-08-23 related to an incident involving residents R1, R2, and R3.
Findings
The incident involved R1 pushing R2, who fell to the floor. R2 was transferred to an acute hospital for a fall and medication review. Upon return, R2 was calm and comfortable. The facility updated R1's care plan to address aggressive behavior. No deficiencies were cited during this visit.
Report Facts
Incident date: Aug 17, 2021
Previous visit date: Aug 23, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced visit and delivered findings |
| Fili Howard | Executive Director | Met with Licensing Program Analyst during visit |
| Angela L Boucher-Turin | Administrator | Facility Administrator named in report header |
Inspection Report
Complaint Investigation
Census: 56
Capacity: 111
Deficiencies: 0
Date: Aug 23, 2021
Visit Reason
The visit was an unannounced follow-up on an incident report (SOC 341) that was reported by the facility involving an incident between residents during breakfast on 08/17/2021.
Complaint Details
The incident involved a resident (R1) extending their arm in a swinging motion and another resident (R2) found on the floor. Staff reported R2 has a tendency to grab other residents' food, and R1 was trying to stop R2 from grabbing R3's food. The investigation is ongoing.
Findings
The Licensing Program Analyst interviewed involved staff and residents, observed the dining room, and requested additional documentation. The incident requires further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced visit and investigation. |
| Julio Montes | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Fili Howard | Executive Director | Met with the Licensing Program Analyst during the visit and discussed the report. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 111
Deficiencies: 0
Date: Jul 28, 2021
Visit Reason
The visit was a Case Management investigation regarding an Incident Report received by the Community Care Licensing Division involving a female resident and a male caregiver.
Complaint Details
The visit was triggered by an incident report alleging inappropriate conduct by a male caregiver with a female resident. The investigation is ongoing, with interviews conducted by facility management and police. The caregiver was removed from the facility pending investigation.
Findings
The investigation involved an incident where a caregiver was found undressed with a resident in the restroom and later found in a resident's room with two residents. The facility management and police conducted interviews, and the caregiver was instructed to leave the facility pending investigation.
Report Facts
Capacity: 111
Census: 46
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela L Boucher-Turin | Executive Director | Interviewed during the investigation and involved in instructing the caregiver to leave the facility |
| Mohamed Filouane | Licensing Program Analyst | Conducted the Case Management visit and reviewed the incident report |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 111
Deficiencies: 0
Date: Jun 23, 2021
Visit Reason
The visit was an unannounced follow-up on two incident reports involving resident-to-resident altercations during meal services in the dining room.
Complaint Details
The visit was triggered by two incident reports involving resident altercations. The incidents were investigated and the facility took corrective actions including increased supervision and care plan updates. No further incidents were reported.
Findings
The facility reported two incidents involving resident altercations with some injuries in the first incident and no injuries in the second. The facility increased supervision, updated the care plan, and provided one-on-one feeding assistance for the involved resident. No deficiencies were cited during the visit.
Report Facts
Number of caregivers during meal service: 3
Incident dates: First incident on 2021-06-05 and second incident on 2021-06-13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela L Boucher-Turin | Executive Director | Met with Licensing Program Analyst during visit and discussed findings |
| Murial Han | Licensing Program Analyst | Conducted the unannounced visit and investigation |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 111
Deficiencies: 0
Date: Mar 1, 2021
Visit Reason
Unannounced visit/investigation of a complaint received on 2019-11-25 regarding a resident sustaining fractures while in care.
Complaint Details
Complaint was unsubstantiated based on investigation findings including physician reports and staff interviews indicating procedures were in place to prevent the alleged incident.
Findings
The investigation included record reviews, physician reports, medical assessments, and staff interviews. A procedure was in place for bolting furniture in the resident's room. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 14
Complaint Control Number Suffix: 20191125145436
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation and tele-visit. |
| Angela Boucher-Turin | Administrator | Met with Licensing Program Analyst during investigation. |
Inspection Report
Complaint Investigation
Census: 45
Capacity: 111
Deficiencies: 2
Date: Nov 25, 2020
Visit Reason
Unannounced complaint investigation visit conducted due to allegations that a resident at risk of infection had not received showers for months and did not receive safe healthful accommodations.
Complaint Details
The complaint was substantiated based on interviews and records review, confirming that the resident did not receive regular showers and did not have safe healthful accommodations as required.
Findings
The investigation substantiated that the facility did not provide regular showers to the resident, instead providing sporadic showers and sponge baths, failing to ensure basic services and safe, healthful accommodations, posing an immediate health, safety, or personal rights risk.
Deficiencies (2)
Failure to provide Basic Services including regular showers to resident R1, posing an immediate health, safety or personal rights risk.
Failure to provide safe, healthful, and comfortable accommodations to resident R1, posing an immediate health, safety or personal rights risk.
Report Facts
Capacity: 111
Census: 45
Plan of Correction Due Date: Nov 27, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela Boucher-Turin | Administrator | Named in relation to findings and discussion of the report. |
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation. |
| Brenda Chan | Licensing Program Manager | Oversaw the complaint investigation report. |
| Tod Murray | Administrator | Met with during the investigation. |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 111
Deficiencies: 1
Date: Nov 20, 2020
Visit Reason
The inspection was an unannounced complaint investigation triggered by a complaint received on 10/29/2020 regarding a resident not receiving showers due to lack of staff.
Complaint Details
The complaint was substantiated. The allegation that a resident did not receive showers due to lack of staff was found valid based on evidence including staff interviews and documentation.
Findings
The investigation found that the resident had not received showers since June 2020 and was given sponge baths instead due to a staff shortage. The allegation was substantiated based on the preponderance of evidence.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in a resident's care plan being changed from regular showers to sponge baths due to lack of staff.
Report Facts
Capacity: 111
Census: 55
Deficiency Type A: 1
POC Due Date: Nov 21, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bertha Raygoza | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Angela L Boucher-Turin | Administrator | Facility administrator involved in the investigation |
| Tod Murray | Administrator | Facility administrator involved in the investigation and report discussion |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 111
Deficiencies: 1
Date: Nov 20, 2020
Visit Reason
The visit was an unannounced case management virtual visit conducted during the investigation of complaint 14-AS-20201029181101 regarding a resident whose level of care changed and who became dependent on others for all activities of daily living.
Complaint Details
Investigation of complaint 14-AS-20201029181101 found that the resident's condition changed to require three person assist and the facility failed to obtain authorization to retain the resident with prohibited health conditions.
Findings
The facility retained a resident with prohibited health conditions without requesting an exception or obtaining authorization, and no provisions were made to transfer the resident to a higher level of care. The care plan was changed from regular showers to sponge baths due to the resident's increased care needs.
Deficiencies (1)
Retention of a resident who became dependent on others to perform all activities of daily living without requesting an exception or obtaining authorization, violating Section 87615 (a) (5) Prohibited Health Conditions.
Report Facts
Capacity: 111
Census: 55
Deficiency Type A: 1
Plan of Correction Due Date: Nov 21, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bertha Raygoza | Licensing Program Analyst | Conducted the unannounced case management virtual visit and authored the report |
| Brenda Chan | Licensing Program Manager | Supervisor overseeing the inspection |
| Angela L Boucher-Turin | Administrator | Facility administrator present during the visit |
| Tod Murray | Administrator present during the visit |
Inspection Report
Census: 55
Capacity: 111
Deficiencies: 0
Date: Nov 19, 2020
Visit Reason
The visit was a Case Management - Other type of unannounced inspection to review infection control and COVID-19 related concerns at the facility.
Findings
The report noted concerns about three non-COVID residents residing in the MCU positive area with a delay in moving to the non-COVID area, which was rectified. Staff crossover between MCU and assisted living was a concern, with positive COVID-19 staff exposure leading to quarantining of four AL residents. Recommendations were made regarding PPE use, staff working at other facilities, and infection control practices.
Report Facts
Residents in MCU positive area delayed moving: 3
AL residents exposed and quarantined: 4
Facility capacity: 111
Facility census: 55
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Angela L Boucher-Turin | Administrator | Named as facility administrator involved in infection control and staff management |
| Tod Murray | Administrator | Named as facility administrator involved in infection control and report discussion |
| Brenda Chan | Licensing Program Manager | Named as licensing program manager overseeing the visit |
| Bertha Raygoza | Licensing Program Analyst | Named as licensing program analyst involved in the visit |
| Cynthia Browning | Corporate Nurse | Named as nurse consultant involved in infection control recommendations |
Inspection Report
Monitoring
Census: 55
Capacity: 111
Deficiencies: 3
Date: Nov 14, 2020
Visit Reason
The visit was an unannounced case management tele-visit conducted due to COVID-19 procedures to monitor the facility's compliance with pandemic-related reporting requirements.
Findings
The facility was found to be inconsistent in submitting required daily COVID-19 linelists to Community Care Licensing on 11/10, 11/11, and 11/12. Additionally, a COVID-19 positive staff case on 11/6 was not reported within the required 24-hour timeframe, and the facility failed to submit requested staff rosters on 11/11 and 11/12.
Deficiencies (3)
Failure to submit the required daily linelist on 11/10, 11/11, and 11/12 to Community Care Licensing, posing a potential health and safety risk to residents.
Failure to report a staff member's positive COVID-19 test on 11/6 within 24 hours as required.
Failure to submit staff roster as requested on 11/11 and 11/12, posing a potential health and safety risk to residents.
Report Facts
Deficiencies cited: 3
Plan of Correction Due Date: Nov 16, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Todd Murray | Met with Licensing Program Analyst during tele-visit | |
| Christopher Hopkins-Clarke | Licensing Program Analyst | Conducted the unannounced case management visit and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
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