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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 12/11/2023
Date Signed: 12/11/2023 01:18:37 PM


Document Has Been Signed on 12/11/2023 01:18 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
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: 75DATE:
12/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Greg BogartTIME COMPLETED:
01:30 PM
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In response to Suspected Abuse Reports (SOC341) submitted to CCLD on 12/1/23 and 12/6/23, LPA Jeung met with administrator to discuss incidents and obtain updates. LPA reviewed clients' files and interviewed clients and staff. Incident reported on 12/1/23 pertains to client #1. Incident reported on 12/6/23 pertains to clients #2 and #3. Administrator is instructed to submit Unusual Incident Reports (LIC624) to CCLD whenever SOC341s are submitted. Administrator to submit completed Incident Reports to CCLD BY 12/12/23 with detailed summary of facility investigations, including names of all persons involved and contacted.

Administrator reported to CCLD on Friday 12/8/23 that facility is experiencing a gastrointestinal outbreak. LPA is informed today that report was made to SF Dept. of Public Health, and recommendations were provided to administrator; copy of SFDPH recommendations obtained by LPA, as well as line list of those afflicted.

Administrator is reminded to ensure that all resident appraisals and care plans are signed and acknowledged by resident or their authorized representatives.

At this time, no deficiencies observed.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 12/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/11/2023
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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