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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:02:03 PM

Document Has Been Signed on 05/29/2024 04:02 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:
05/29/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Roxann King, LVNTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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On May 29, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 2:00 PM, to complete the Annual 1-year required inspection. LPA Calandra was greeted by Roxann King, Director of Memory Care and Assisted Living and explained the purpose of the visit.

LPA Calandra reviewed 5 resident files and 3 staff files.

No deficiencies were cited during today's visit.

The Annual inspection will be completed at a later date.

This report was reviewed with Roxann King, Director of Memory Care and Assisted Living and a copy of the report left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/29/2024
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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