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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 08/15/2023
Date Signed: 08/30/2023 05:39:25 PM

Document Has Been Signed on 08/30/2023 05:39 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: 297DATE:
08/15/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Administrator Glen Goddard, and Director of Memory Care/Assisted Living, Roxann King TIME COMPLETED:
01:40 PM
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On August 15, 2023, Licensing Program Analysts (LPAs) Murial Han and John Calandra arrived unannounced to conduct an annual continuation for an annual required inspection conducted on 5/17/2023. LPAs met with administrator, Glen Goddard, Infection Control Preventionist Janet Prado and Director of Memory Care/Assisted Living Roxann King. LPAs explained the purpose of the visit.

During today's visit, LPAs reviewed staff records that contained criminal clearance to work at the facility and are associated with the facility. In addition, the records also included first aid certificate, health screening with TB test result and criminal record statement. Staff training contains 40 hours of initial training and 20 hours of training annually.

LPA also interviewed 2 Assisted Living residents.

No deficiencies cited today.

This report is reviewed and discussed with Memory Care/Assisted Living Director.

A copy is provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 08/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/15/2023
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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