Inspection Reports for Sagebrook Senior Living

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.

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.

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.

The visit was an unannounced follow-up inspection to investigate a reported incident involving a resident leaving the facility unassisted.

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.

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.

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.

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.

An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with regulatory standards.

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.

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.

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.

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.

The unannounced visit was conducted to follow up on a facility reported incident involving a resident eloping from the facility without supervision.

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.

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.

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.

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.

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.

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.

The inspection visit was conducted to continue the Annual 1-year required inspection of the facility.

No deficiencies were cited during the visit. Resident and staff records were reviewed and found to be complete.

The visit was conducted to perform a Plan of Correction (POC) inspection at the facility.

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.

The inspection was an unannounced Annual 1-year required inspection conducted to evaluate compliance with licensing regulations.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted in response to allegations received on 2023-04-27 regarding facility maintenance and safety concerns.

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.

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.

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.

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.

The complaint investigation was unsubstantiated as the allegations of inadequate food service, failure to meet residents' needs, and medication mismanagement could not be proven.

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.

The visit involved reviewing documentation related to the incident; no deficiencies were cited during this inspection.

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.

The inspection visit was conducted as an unannounced complaint investigation following a complaint alleging that staff illegally evicted a resident.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by a complaint alleging that the facility failed to provide adequate food service.

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.

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.

An unannounced annual inspection was conducted to evaluate compliance with licensing requirements and infection control practices.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was an unannounced follow-up on an incident report regarding an allegation that a staff member pulled a resident's ponytail.

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.

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.

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.

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.

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.

The Licensing Program Analyst interviewed involved staff and residents, observed the dining room, and requested additional documentation. The incident requires further investigation.

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.

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.

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.

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.

The visit was an unannounced follow-up on two incident reports involving resident-to-resident altercations during meal services in the dining room.

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.

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.

Unannounced visit/investigation of a complaint received on 2019-11-25 regarding a resident sustaining fractures while in care.

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.

Complaint was unsubstantiated based on investigation findings including physician reports and staff interviews indicating procedures were in place to prevent the alleged incident.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The visit was a Case Management - Other type of unannounced inspection to review infection control and COVID-19 related concerns at the facility.

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.

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.

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.