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Inspection visit

Incident investigation

SAGEBROOK SENIOR LIVING AT SAN FRANCISCOLicense 3856004231 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 9/13/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on a facility reported incident and met with Program Director Peter Nixdorff. The incident occurred on 8/25/2024 involving resident (R1) eloping from the facility without supervision. R1 had been observed in the facility common area the previous evening on 8/24/2024. During morning medication pass, staff did not observe R1 in their bedroom. Program Director immediately notified local police department, R1's responsible party and Community Care Licensing. R1 was located at a nearby medical center and found to have no injuries or significant changes of condition. Upon review of records, it is found that R1 is unable to leave the facility unassisted. The facility has updated R1's level of care including more frequent room checks, updated R1's physician's report and will be meeting with R1's responsible party for revised needs & service plans. In addition the facility has implemented front door security with secured door hours from 4pm - 8am, and utilizing overnight front desk attendance. R1 has not demonstrated any further behaviors of exit seeking and the facility has implemented appropriate measures to ensure no further incidents occur. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

Citations

1 citation recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87464(f)(1)Type B

    Care and supervision as defined by statute and rules

    87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Codesection 1569.2(c). This was not met as evidence by**: Based upon facility incident report, interviews with staff and a review of resident records, it was found that R1 had AWOL from the facility without staff supervision. This serves a potential health & safety risk to resident in care.

FAQ · About this visit

Common questions about this visit

What happened during the September 13, 2024 inspection of SAGEBROOK SENIOR LIVING AT SAN FRANCISCO?

This was an other inspection of SAGEBROOK SENIOR LIVING AT SAN FRANCISCO on September 13, 2024. 1 citation were issued: 1 Type B.

Were any citations issued to SAGEBROOK SENIOR LIVING AT SAN FRANCISCO on September 13, 2024?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section..."

What type of inspection was this?

This was an other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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Data from CCLD public records. Last updated . If you believe any information is inaccurate, report it here.