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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 05/25/2023
Date Signed: 05/25/2023 12:45:24 PM

Document Has Been Signed on 05/25/2023 12:45 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:SEQUOIAS SAN FRANCISCO (THE)FACILITY NUMBER:
380500593
ADMINISTRATOR:GLEN GODDARDFACILITY TYPE:
741
ADDRESS:1400 GEARY BLVDTELEPHONE:
(415) 922-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY: 400CENSUS: DATE:
05/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Glen GoddardTIME COMPLETED:
12:30 PM
NARRATIVE
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LPA Jeung met with executive director and discussed observations made on 5/17/23 during annual inspection conducted by LPA Han.

On 5/17/2023, during LPA Han's annual inspection, it was discovered that the facility has multiple confirmed cases of COVID-19. However, this was not reported to CCLD in a timely manner.

Based on the facility COVID-19 report provided by the facility during the visit on 5/17/23, 5 facility staff and 1 resident were diagnosed with COVID-19 from 5/11/2023- 5/13/2023 and the confirmed cases continued to rise on a daily basis thereafter.

According to the Infection Control Preventionist, the initial call was made to CCL on 5/15/2023. Based on Title 22, CCR 87211 Reporting Requirements, epidemic outbreaks shall be reported within 24 hours either by telephone or fax to licensing agency. The last COVID reported was on 5/20/23. Updated and complete line list is provided to LPA today.

Deficiency of the California Code of Regulations, Title, 22, is cited today as the facility failed to report an epidemic outbreak within 24 hours. See LIC 809D. Failure to correct the deficiency may result in civil penalties.

This report is reviewed and discussed with Mr. Goddard.

A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 05/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/25/2023
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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Document Has Been Signed on 05/25/2023 12:45 PM - It Cannot Be Edited


Created By: Audrey Jeung On 05/25/2023 at 10:13 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: SEQUOIAS SAN FRANCISCO (THE)
FACILITY NUMBER: 380500593

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/26/2023
Section Cited
CCR
87211(a)(2)

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Reporting Requirements
a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:..(2) Occurrences, such as epidemic outbreaks, shall be reported within 24 hours either by telephone or facsimile..
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The administrator/licensee will develop a plan to ensure compliance and the plan will include staff training.
The administrator/licensee will submit a copy of the plan BY DUE DATE
Copy of the in-service staff training record will be submitted to CCL within 5 days of training.
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This requirement was not met as evidenced by facility failed to report COVID-19 epidemic outbreaks within 24 hours which posed immediate health, safety or personal rights risks to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Cara Smith
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 05/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/25/2023


LIC809 (FAS) - (06/04)
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