Sagebrook Senior Living at San Francisco.

On 3/11/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an incident that occurred on February 19th, 2026 in which R1 was able to elope from the facility. According to the Administrator, R1 left the facility early in the morning before the concierge started and was located on the sidewalk in front of the facility. R1 stated to facility staff that they were going to get food. R1 was redirected back into the facility and no injuries were observed. R1 now has a 1:1 caregiver and has not eloped since the incident or shown wander seeking behaviors. A Type B citation was provided for this deficiency. During the visit, LPA received copies of R1's latest Appraisal of Needs and Services and the resident's latest Physician's report. An exit interview was conducted. A copy of the report along with Appeal Rights were provided.

On 12/15/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Annual 1-year required inspection. LPA Calandra was greeted by Juvy Valera, Receptionist and explained the purpose of the visit. Peter Nixdorff, Executive Director arrived later during the visit. LPA toured the physical plant. This is a 3-story building with 78 bedrooms, 74 bathrooms, a kitchen, backyard, and common spaces. All bedrooms had the required furniture and sufficient lighting. All bathrooms had slip resistant flooring and grab bars. The facility was maintained at a comfortable temperature. No accessible bodies of water or hazards were observed. The facility's hot water temperature was measured within the required 105-120 degrees Fahrenheit. The facility had the required 7 days of non perishables and 2 days of perishables on site. No food was expired. The facility's fire alarm and carbon monoxide detector were observed to be in working order. The facility's first aid kit had the required items. All soap, sharp objects, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 5 resident files and 6 staff files. All were observed to be complete. This facility does not handle cash resources. LPA received copies of the following documents while at the facility: Administrator's Certificate Current LIC 500-staff roster and resident roster Liability Insurance 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 26 27 28 29 30 31 32 A review of Centrally Stored Medications 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. In addition, per conversation with the Executive Director the facility has 1 staff member per shift that has active CPR and First Aid Training. During document review, LPA was not provided with documentation. A Type B citation was provided for this deficiency. When LPA arrived at the facility to conduct the Annual Audit, LPA asked to review staff and resident records. LPA was told by S1 that no one at the facility currently could access said files. Two hours after the LPA arrived at the facility, files were made accessible. A Type B citation was provided for this deficiency. Deficiencies are cited under the California Code of Regulations. Failure to correct the deficiencies by the POC due date may result in Civil Penalties. An exit interview was conducted. This report was reviewed with facility representative and a copy provided.

Allegation, above is found to be SUBSTANTIATED. A finding that the complaint is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Civil Penalty was assessed for incident resulting in injury of resident.

On 1/8/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Executive Director, Peter Nixdorff. The facility currently provides care for 62 residents, 4 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 and kitchen were found to be last charged. Carbon monoxide detectors were located at each hallway tested and functioning. Smoke and sprinkler systems are interconnected with a fire safety inspection conducted by separate outside agency. Water at faucets accessible to residents were measured and found to be within regulation. All resident restrooms are equipped with non-slip mats and grab bars for accessibility. During the inspection, LPA observed oxygen tank in resident bedroom without appropriate signage posted. Executive Director immediately contacted staff to place sign indicating oxygen in use. 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 three times per week and stored properly. Facility provides a wide variety of meal preferences and preparation while also ensuring proper dietary restrictions are followed. Cleaning supplies and other toxins are safely stored in locked closets throughout each floor, and housekeeping/maintenance rooms all of which were secured upon inspection. There was a supply of hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings and bedding items. During inspection of resident bedroom, LPA located a tool bag left by residents family that held items potentially dangerous to residents in care. Executive Director immediately contacted resident's family member notifying of the concern and placed the tool bag in a secured staff office. Executive Director agrees to further discuss with resident family on safety risks. Technical Violation issued. Continued onto LIC809-C 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 26 27 28 29 30 31 32 Residents that were awake during 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. LPA found that staff and resident engagement is well practiced with activities observed throughout the day. Residents were observed to have a positive and personable relationship with staff and Executive Director and were often out in the community during the inspection. There is a large outdoor patio for resident use, equipped with appropriate shading. A spot check of medications was conducted and found that all medication counts and records are in order. Medtech staff were knowledgeable of all medication administration and destruction procedures. LPA conducted a sample file review for residents and found all items to be in order including medical assessments and needs & service plans. Upon a spot check of staff files, LPA found that caregiver staff have current 1st aid and CPR on file. Peter Nixdorff's Administrator Certificate 7014086740 is currently active through 1/26/2025 . LPA requested the following documents be sent to CCL by COB 1/22/2024: LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary LIC 610 Emergency Disaster Plan Liability Insurance

On 9/13/2024, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of following up on a facility reported incident and met with Program Director Peter Nixdorff. The incident occurred on 8/25/2024 involving resident (R1) eloping from the facility without supervision. R1 had been observed in the facility common area the previous evening on 8/24/2024. During morning medication pass, staff did not observe R1 in their bedroom. Program Director immediately notified local police department, R1's responsible party and Community Care Licensing. R1 was located at a nearby medical center and found to have no injuries or significant changes of condition. Upon review of records, it is found that R1 is unable to leave the facility unassisted. The facility has updated R1's level of care including more frequent room checks, updated R1's physician's report and will be meeting with R1's responsible party for revised needs & service plans. In addition the facility has implemented front door security with secured door hours from 4pm - 8am, and utilizing overnight front desk attendance. R1 has not demonstrated any further behaviors of exit seeking and the facility has implemented appropriate measures to ensure no further incidents occur. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

On January 11, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:04 AM to conduct an unannounced Annual 1-year required inspection. LPA Calandra met with Laura Richardson, Program Director. Faimfili Howard, Executive Director arrived later and joined the visit. LPA Calandra toured the physical plant. This is a 3-story building that consists of 79 rooms and 79 bathrooms. Water in all bathrooms was measured between the required 105-120 degrees Fahrenheit. Bathrooms were observed to have the required grab bars and anti-skid mats. Fire extinguishers in the facility were observed to be fully charged and last checked on July 6, 2023. The facility had the required 7 days of non-perishables and 2 days of perishables on site. No food was expired. The kitchen refrigerators and freezers temperature was within the required range. All bedrooms were sufficiently lit and had the required furniture. The backyard was clear from obstructions. No accessible bodies of water or hazards were observed. The facility's first aid was observed to be complete. The facility does not handle any cash resources at this time. LPA Calandra received Consolidated Emergency Response/Contingency Plan and Floor plans. All knives and sharp objects were observed to be locked and in-accessible to persons in care. All medications, soaps, and detergents were observed to be locked and in-accessible to persons in care. A review of Centrally stored medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication records kept at the facility. 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 26 27 28 29 30 31 32 LPA Calandra requested the following documents from the facility be sent via email or fax to the RO: -Job description/Personnel policies/on-the-job training -Fire Clearance -Health Screening Reports-Facility Personnel(LIC 503) -Plan of Operation -Plan for Incidental Medical and Dental Care -Qualifications of Administrator-Admin Certificate -Affidavit Regarding Client/Resident Cash Resources (LIC 400) During the tour of the physical plant, LPA observed S1 sitting on a bench in the hallway of Assisted Living, Floor 2. LPA asked staff member, their name, and S1 stated their name. LPA checked Facility Personnel Summary Report and could not find a staff member listed with that name. During a tour of the Assisted Living dining room, LPA stopped and spoke with S2 and asked S2 their name. S2 stated their name and LPA looked at the Facility Personnel Summary Report but again could not find anyone listed. LPA then called the RO and asked support staff to look up both staff. Support staff could not find S1 associated to the facility and S2 does not have criminal record/fingerprint clearance. LPA spoke to Executive Director about S1 and S2 and explained that until S2 has fingerprint/criminal record clearance, they cannot work. LPA explained that civil penalties would be assessed for both deficiencies. 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 26 27 28 29 30 31 32 During today's visit a Civil Penalty of $1,000 was assessed for failure to ensure all individuals subject to a criminal record review were approved for a transfer of a criminal record exemption, as specified in Section 87355 and failure to obtain a California clearance or a criminal record exemption as required by the Department. Civil Penalty is $100 a day per staff member (2x) for the period of 1/6/2024-1/11/2024. The Annual will be completed at a later date. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. The report was reviewed with Executive Director, Fili Howard and a copy along with Appeal rights were left at the facility.

During the tour of R1's room, LPAs attempted to open and close the bathroom window but it was very tight. R1 attempted to open and close the window, however, R1 was not able to do so due to the tightness of the window. The sales and marketing director was able to open and close the bathroom window but acknowledged that it took a lot of strength. The administrator and the maintenance director were not aware of the bathroom window problem in R1's room, however, after attempting to open and close it, they acknowledged that it was tight, it took a lot of strength to operate it and it would be hard for R1 to open and close it. The maintenance director spray WD-40 oil around the window frame to loosen it but it was not successful. After the investigation, this allegation is deemed to be substantiated. Based on interviews, observations and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided.