Sagebrook Senior Living At San Francisco

On 4/10/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Peter Nixdorff. LPA toured the facility, interviewed staff and outside parties and reviewed resident records during the course of the investigation. Complaint alleges resident sustained multiple injuries due to neglect/lack of supervision. Based upon review of R1’s records it is determined that R1 had sustained three separate incidents in which R1 had been involved in multiple unwitnessed falls. The facility completed an updated care appraisal, implementing an increased level of care for more frequent room checks, staff escort to activities and common spaces, transferring from sitting to standing and use of a walker due to the identified high fall risk, confusion and diagnoses of Parkinson's and major neurocognitive disorder. Facility however, failed to update R1's medical assessment corresponding to R1's updatedRead the full finding— CDSS inspection report, April 10, 2025 · control 14-AS-20250113143203

On 1/8/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of delivering complaint investigation findings and was greeted by Executive Director, Peter NIxdorff (S1). LPA toured the facility, interviewed staff, resident and outside party, reviewed facility records and made observations during the course of the investigation. Complaint alleges staff did not maintain a comfortable temperature for residents in care after facility heating system had become damaged. Based upon tour of the facility, LPA found that the heating system only allows an "on and off" control with no thermostat to indicate exact temperature. During LPA's multiple facility visits, the facility was found to be at a comfortable temperature and not observed to be cold or signs of residents in discomfort. In addition, the facility had provided additional blankets and individual space heaters to residents affected. Interviews with Maintenance Director (S2) it was found that bedrooms 300, 301, 3Read the full finding— CDSS inspection report, January 8, 2025 · control 14-AS-20241120150635

On 9/13/2024, Licensing Program Analyst (LPA) conducted an unannounced visit to delivery the complaint investigation findings. LPA met with Program Director, Peter Nixdorff and explained the purpose of today's visit. Regarding to the allegation of lack of supervision- the reporting party stated that memory care staff leaves the residents in the lunch hall for an extended periods of time so they don't have to move the residents back and forth from their rooms, and if the residents soiled themselves while waiting, the staff leaves the residents until after lunch to change them. The reporting party also reported that a resident with vision problem isolates him/herself in the room because its the only environment that he/she can navigate independently. In addition, a resident slipped out of the wheelchair while getting fresh air. As part of the investigation, LPA Han and LPA Tobola interviewed Memory Care Director, facility staff, resident #1(R1), resident #2(R2), and other residents. ContRead the full finding— CDSS inspection report, September 13, 2024 · control 14-AS-20240731085313

On August 15, 2023, Licensing Program Analysts (LPA) Murial Han and LPA John Calandra conducted an unannounced 10-day complaint inspection. LPAs met with Sales Director, David Estrada and explained the purpose of today's visit. The administrator and maintenance director arrived shortly thereafter and assisted with the rest of the inspection. During today's visit, LPAs toured resident-in-question (R1)'s room, tested the bathroom window, interviewed administrator and maintenance director. Regarding to allegation of - staff did not repair resident's window, during the initial reporting, the reporting party stated that R1's bathroom window is very hard to open and close and the reporting party is worried that R1 would get hurt while doing that. SubstantiatedRead the full finding— CDSS inspection report, August 15, 2023 · control 14-AS-20230808165248

On 5/31/2023 Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20230427140227. LPA Han met with administrator and explained the purpose of the visit. Regarding to allegation of - facility did not repair resident's window, the reporting party stated that resident #1 (R1) has been residing at the facility for 2 years and the window in the room has never operated correctly. The responsible party and the reporting party has made many requests verbally and in writing to fix the window but it is still inoperable. As part of the investigation, LPA toured R1's room, interviewed maintenance director, administrator and reviewed written communication correspondences. SubstantiatedRead the full finding— CDSS inspection report, May 31, 2023 · control 14-AS-20230427140227

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver findings regarding the above allegations. LPA met with health and wellness director Jennine Chan and explained the purpose of today's visit. During the investigation LPA conducted multiple interviews, reviewed pertient complaint documents, and obtained photos. The above allegations could not be proved or disporved by LPA during the investigation process. LPA could not meet the perponderance of evidence standard to prove that they did take place. These allegations are unsubstantiated. Report is reviewed with Jennine Chan. No citations issued. UnsubstantiatedRead the full finding— CDSS inspection report, May 24, 2023 · control 14-AS-20200803161119

On 5/3/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20230309165530. LPA Han met with sales director and LPA explained the purpose of the visit. Regarding to allegation of- staff illegally evicted resident, the reporting party stated that he/she did not report it. However, CCL received this complaint, and LPA conducted an investigation. As part of the investigation, LPA interviewed facility administrator, and R1's case manager. LPA interviewed the administrator who denied the eviction and stated that R1 was admitted from a hospital with a plan to stay at the facility for 30 days then return home. After the 30 days, the facility was directed by R1's case manager that R1 wanted to return home as planned and the facility worked with R1's case manager to get R1 home. UnfoundedRead the full finding— CDSS inspection report, May 3, 2023 · control 14-AS-20230309165530

On 3/15/2023, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings to complaint # 14-AS-20221230101902. LPA Han met with the Sales Director and the resident service director. LPA explained the purpose of the visit. Regarding allegation of - facility failed to provide adequate food service, the reporting party stated that, resident -in- question (R1) reported that the facility served bad hamburger and uncooked hot dogs, the facility did not provide the foods that R1 had requested for and instead, provided the foods that R1 did not order and R1 was told by staff that there was no snacks available. LPA interviewed the administrator who denied the allegation and stated that R1 did not like hamburger as R1 did not eat it until 4 hours later and the hot dog was fully cooked but the way it was cooked left the center a little pinkish. The administrator also stated that there is always snacks such as chips, cookies and fruits in the dining room bistrRead the full finding— CDSS inspection report, March 15, 2023 · control 14-AS-20221230101902