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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 11/20/2024
Date Signed: 11/20/2024 02:16:34 PM

Document Has Been Signed on 11/20/2024 02:16 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: 264DATE:
11/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Glen Goddard, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
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On 11/20/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a health & safety check regarding incident report dated 11/5/2024 and received by the Regional Office on 11/6/2024 involving the health status of resident (R1) and was greeted by Executive Director, Glen Goddard and Director of Assisted Living and Memory Care, RoxAnn King. The incident involves resident (R1) being hospitalized for having ingested an illegal substance. LPA Tobola interviewed both Executive Director and Director of Assisted Living and Memory Care, toured the facility, gathered facility and resident records and made observations.

LPA found that the facility had reported the incident involving R1 in a timely manner along with additional documentation submitted to all appropriate agencies and outside parties.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2024
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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