380500593-5-16-2025-14-AS-DTOA-DGQTWU-20250516150608

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380500593
Report Date: 05/16/2025
Date Signed: 05/16/2025 03:07:01 PM

Document Has Been Signed on 05/16/2025 03:07 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 GODDARD		FACILITY TYPE:	741
ADDRESS:	1400 GEARY BLVD		TELEPHONE:	(415) 922-9700
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94109
CAPACITY: 400		CENSUS: 31	DATE:	05/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:02 AM
MET WITH:	Terrence , Administrator,Tomas Mendez , Executive Director & Health & Director of Assisted Living and Memory Care, RoxAnn King		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 5/16/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Administrator, Terrence Tumbale, Executive Director, Tomas Mendez & Director of Assisting and Memory Care, RoxAnn King. The facility currently provides care for 31 residents in the assisted living and memory care units, 2 of which are receiving hospice services, along with a designated memory care unit. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located on each resident floor, kitchen and common spaces were found to be charged. A spot check of medications in the assisted living and memory care units, was conducted and found that all medication counts and records are in order. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen, sufficient for residents in care. Food supply is replenished multiple times throughout the week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. There was a supply of hygiene products and paper products available for residents with replenishment throughout the week. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. LPA observed a housekeeping cart located outside of the housekeeping closet within the assisted living portion of the facility. Light cleaning supplies were observed unsecured and potentially accessible. House keeping was actively working on their routine during inspection with no residents observed near the cart. Items were immediately stored in secured location and will be discussed with staff. Technical Violation issued. Continued onto LIC809-C

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 05/16/2025

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Residents that were out in the community the inspection were observed interacting with staff, fellow residents and visitors in the common areas, or in their bedrooms resting. The facility encourages regular family visits and utilizes a wide variety of activities with LPA observing staff engaging continuously with residents, offering activities based on individualized preferences and abilities. LPA found that staff and resident engagement is well practiced with activity calendars developed on a monthly basis. The facility also integrates memory care residents into facility wide events and activities to promote inclusion and interaction. Residents were observed to have a positive and personable relationship with staff. There are two outdoor patios for resident use, all equipped with appropriate shading and a large sun room plaza for resident use.

LPA conducted a sample file review for residents and found all items to be in order including needs & service plans and physician's reports. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR and annual training and health screening reports on file. LPA noted that Administrator, Terence Tumbale is associated to a partnered facility under the same license but not to the Sequoias San Francisco. LPA discussed with Administrator and provided technical assistance.

Terence Tumbale's Administrator Certificate 7018528740 is currently active through 2/25/2027.
Roxanne King's Administrator Certificate 6075229740 is currently active through 3/4/2027.

LPA requested the following documents be sent to CCL by COB 5/30/2025:

LIC 308 Designated Facility Responsibility
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
Liability Insurance

No deficiencies cited during today's visit.

NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 05/16/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2025

LIC809 (FAS) - (06/04)

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