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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 04/03/2023
Date Signed: 04/03/2023 11:48:34 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
03/27/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230327110439
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: 69DATE:
04/03/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Jeffrey Dillon TIME COMPLETED:
11:58 AM
ALLEGATION(S):
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9
Staff did not repair a resident's medical bed while in care
INVESTIGATION FINDINGS:
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On April 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Jeffrey Dillon nd Director of Wellness, Renafe Mosquera and explained the purpose of the visit.

Regarding the allegation that staff did not repair a resident's medical bed while in care, according to the reporting party, staff reported that Resident 1's (R1's) bed had been broken and not working for a while and could not be adjusted to sit R1 upright.

During the investigation, LPA toured facility, observed R1's bed, and interviewed the Administrator and the Director of Wellness. According to the Administrator and the Director of Wellness, it was acknowledged that R1's medical bed was not working. The Director of Wellness had the Maintenance Director check the bed and found that the electical outlet was not working. During the visit today, LPA observed the bed to be in good repair and working condition.

Based on interviews and observations conducted during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is 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 is reviewed with Administrator and Director of Wellness and a copy is provided with appeals rights.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
03/27/2023 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230327110439

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: 69DATE:
04/03/2023
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Jeffrey Dillon TIME COMPLETED:
11:58 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not properly position a resident while in care
INVESTIGATION FINDINGS:
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On April 3, 2023, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Jeffrey Dillon and explained the purpose of the visit.

Regarding the allegation, staff did not properly position a resident while in care, according to the reporting party, on 2/23/23 staff were asked to provide extra pillows to paramedics to assist Resident 1 (R1) into a semi-fowler position, however pillows were not provided.

During the investigation, LPA interviewed the Care Team that were present and working the day of the incident. Staff interviews indicated when paramedics arrived to the facility, they requested pillows to put R1 in an upright position to help R1's nose bleed. Care staff immediately provided paramedics with two pillows, and the LVN on shift provided assistance with positioning R1 upright.

Although the above allegation may have happened or are valid, there is no evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with Administrator and Director of Wellness and a copy is provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20230327110439
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/03/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2023
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation : (a) The facility shall be clean, safe, sanitary and in good repair at all times...

Violation of this regulation is evidenced by:
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Deficiency is corrected and cleared. LPA observed R1's bed to be in good repair and working condition.
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Based on observations and interviews conducted, it was acknowledged that the electric hospital bed was broken. According to the Director of Wellness, she had the Maintenance Director check the bed and found that the electical outlet was not working.
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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: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 04/03/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3