385601045-11-19-2020-14-AS-KHOS-BVWR3A-20201202113937

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 11/17/2020
Date Signed: 11/19/2020 11:16:29 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/05/2020 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20201005102322

FACILITY NAME:	PORTOLA GARDENS		FACILITY NUMBER:	385601045
ADMINISTRATOR:	JEFFREY DILLON		FACILITY TYPE:	740
ADDRESS:	350 UNIVERSITY ST		TELEPHONE:	(415) 337-1587
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94134
CAPACITY:	124	CENSUS: 51	DATE:	11/17/2020
		UNANNOUNCED	TIME BEGAN:	03:50 PM
MET WITH:	Jeffrey Dillon		TIME COMPLETED:	04:20 PM

ALLEGATION(S):

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Resident does not have a pull cord.

INVESTIGATION FINDINGS:

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On 11/17/20, Licensing Program Analyst (LPA) Mohamed Filouane, conducted a follow-up complaint inspection with Administrator Jeffrey Dillon, through video call and over the phone. LPA called the Administrator because of COVID19 and safety measures for social distancing. LPA spoke with the Administrator, explained the purpose of the phone call, and then delivered the findings.

In regard to the allegation concerning the resident not having a pull cord, a video call was conducted, staff interviews were completed to verify the call button and/or pull cord was available for the resident, and images were emailed to the LPA. During the video call, the LPA observed the resident did have a pull cord, which was behind the bed of the resident. The LPA also observed a call necklace worn by the resident, as well as the resident laughing and conversing with the Administrator and other staff members in the room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20201005102322

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA GARDENS	FACILITY NUMBER: 385601045
	VISIT DATE: 11/17/2020

NARRATIVE

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The investigation revealed that approximately in early October, the facility's call system was not working. The Administrator stated the facility had fixed the issue in the week that it occurred. During the video call visit on 10/15/20, the LPA also observed a call button behind the bed of the resident. It was on that day that the LPA also requested an additional call button for the resident. The Administrator acquired the additional call pendant the same day for the resident, on 10/15/20.

During interviews with facility staff members, facility staff stated that because of the resident's diagnosis, the resident tends to frequently call for help when there is no physical issue or an urgent matter that requires attention. Facility staff stated the resident is friendly and that they believe the calls for help are ways for the resident to interact with the caregivers and have a conversation.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the Administrator over the phone. The Administrator will receive this LIC9099 report through email to sign. The Administrator will then email the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020

LIC9099 (FAS) - (06/04)

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