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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 08/30/2023
Date Signed: 08/30/2023 11:39:08 AM


Document Has Been Signed on 08/30/2023 11:39 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 GARDENSFACILITY NUMBER:
385601045
ADMINISTRATOR:GREGORY K BOGARTFACILITY TYPE:
740
ADDRESS:350 UNIVERSITY STTELEPHONE:
(415) 337-1587
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:132CENSUS: 69DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Lea Salazar, Administrative AssistantTIME COMPLETED:
11:50 AM
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On 8/30/2023 LPA Grace Donato conducted an unannounced annual visit to the facility. LPA met with Administrative Assistant, Lea Salazar. LPA explained the purpose of the visit.

LPA toured the facility inside and outside including a random sample of resident rooms, common areas, and kitchen area. LPA observed some residents watching tv near the dining area, some residents were outside the facility talking. While touring the facility it was observed that the temperature was at 78 deg F. Hot water was also tested in the resident bathrooms and the temperature was 110 deg F. Bathrooms are equipped with grab bars and non-skid floors. The residents have adequate number of linens and incontinence care items. All personal belongings are intact. Resident bedrooms were observed to be in good repair. Carbon monoxide monitor is working properly. All fire extinguishers have been checked dated 6/8/23. LPA toured the kitchen, and it was observed that anyone entering the kitchen are required to wear hairnets. There is adequate amount of food, 2 days for perishables and & 7 days non-perishable. Food containers are labeled with date opened. Freezers are at required temperature. Emergency drills are done every month.

Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic 20hr requirement. Facility has a certified administrator on site with complete certification and training requirements. Facility accepts hospice residents and are following the required waiver requirements.

Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 08/30/2023
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LPA interviewed 5 residents and 3 staff. All residents stated that they are being well taken care of and enjoys the food. Activities are offered and residents are encouraged to join. All staff are competent with regards to the care of the residents.

LPA received the following documents from the facility:

LIC 400
Certificate of Liability Insurance

No deficiencies are cited at this time. Report is reviewed and a copy is provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Grace DonatoTELEPHONE: (714) 293-8294
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023
LIC809 (FAS) - (06/04)
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