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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:05:32 PM


Document Has Been Signed on 03/25/2022 12:05 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PORTOLA GARDENSFACILITY NUMBER:
385601045
ADMINISTRATOR:JEFFREY DILLONFACILITY TYPE:
740
ADDRESS:350 UNIVERSITY STTELEPHONE:
(415) 337-1587
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:132CENSUS: 64DATE:
03/25/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Abella TolmasoffTIME COMPLETED:
12:15 PM
NARRATIVE
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On this day at 1100 hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit in conjunction with a complaint closure conducted on this day. LPA met with LVN Abella Tolmasoff and explained the purpose of this case management.

It was found during the investigation of a complaint received on 08/31/2021 that a staff person (S1) was not associated to the facility. LPA reviewed the staff roster with Abella and confirmed that S1 is still not associated to the facility but does have a fingerprint clearance.

This violation results in a civil penalty of $100 per day x 10 days = $1,000

Report is reviewed with Abella Tolmasoff. Appeal rights provided.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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Document is an Amendment of Original Document on 03/01/2023 05:17 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
03/26/2022
Section Cited

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Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)
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Administrator shall ensure to submit a criminal record clearance transfer request to the licensing office for S1 by the POC due date. Also submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date. Failure to correct this deficiency by due date may result in a civil penalty of $100 per day.
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This requirement was not met as evidenced by: Based on records review, licensee failed to request a transfer of criminal record clearance for S1 which poses an immediate health and safety risk to clients in care.

On 03/25/2022, LPA confirmed with LVN that S1 is still employed with facility and is providing care and supervision to residents.
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Immediate civil penalty of $1,000 was issued today.

$100 x 10 days = $1,000

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Vivien HelblingTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Cara SmithTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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