385601045-5-20-2021-14-AS-KHOS-C3CHUF-20210525063017

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 05/20/2021
Date Signed: 05/20/2021 05:09:25 PM

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
05/07/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210507152206

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:	132	CENSUS: 51	DATE:	05/20/2021
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Jeffrey Dillon		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff are over medicating a resident.

INVESTIGATION FINDINGS:

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On 05/20/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. Because of COVID-19 and social distancing measures, LPA Filouane called and spoke to Administrator Jeffrey Dillon over the phone and delivered the findings.

Concerning the allegation of staff over-medicating a resident, LPA Filouane interviewed the Administrator, interviewed the resident, as well as reviewed the resident's medication records, physician's report, and plan of care. After review of the resident's medication records, LPA observed accurate medication administered as prescribed.

The Department has investigated the complaint alleging staff members are over-medicating a resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without reasonable basis.

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

Unfounded

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: 05/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021

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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