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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 05/23/2024
Date Signed: 05/23/2024 03:51:19 PM

Document Has Been Signed on 05/23/2024 03:51 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SEQUOIAS SAN FRANCISCO (THE)FACILITY NUMBER:
380500593
ADMINISTRATOR/
DIRECTOR:		GLEN GODDARDFACILITY TYPE:
741
ADDRESS:1400 GEARY BLVDTELEPHONE:
(415) 922-9700
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94109
CAPACITY: 400CENSUS: 272DATE:
05/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Terrence Tumbale, Administrator TIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On May 23, 2024, at 9:30 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Terrence Tumbale, Administrator and explained the purpose of the visit.

LPA Calandra toured the physical plant. This is a 26 story building. Assisted Living occupies one floor and Memory Care occupies one floor. LPA Calandra inspected 4 rooms (2 in Memory Care and 2 in Assisted Living). All bedrooms had the required furniture and sufficient lighting. Hot water in Assisted Living and Memory Care was measured between the required 105-120 degrees Fahrenheit. Fire extinguishers were observed to fully charged and last inspected on January 16, 2024. Fire alarms and carbon monoxide detectors were observed to be in working condition. The fire alarm/carbon monoxide panel was observed to be fully operational. No Hazards nor obstructions were present in exterior terraces/patios, hallways or other areas of the facility. The facility has an evacuation chair on each floor. The facility also has the required 7 days of non-perishables and 2 days of perishables on site. No food in the main kitchen was expired. Food in the Assisted living dining room that was expired was removed and disposed of by Administrator, Terrence Tumbale in the presence of the LPA.

A review of Centrally stored medications in Assisted Living indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility.

LPA Calandra reviewed 5 resident files. All were observed to be complete. LPA to continue reviewing documents during continuation of Annual.

This Annual will be completed at a later date.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/23/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: SEQUOIAS SAN FRANCISCO (THE)
FACILITY NUMBER: 380500593
VISIT DATE: 05/23/2024
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No deficiencies were cited during today's visit.

This report was reviewed with Terrence Tumbale, Administrator and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024
LIC809 (FAS) - (06/04)
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