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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 04/16/2024
Date Signed: 04/16/2024 05:53:53 PM


Document Has Been Signed on 04/16/2024 05:53 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: 81DATE:
04/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Greg Bogart, Lea, DaviTIME COMPLETED:
06:00 PM
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LPA Audrey Jeung toured facility, which consists of shared and private studio apartments--all of which include sink and vanity--on ground and 2nd floors of this 3- story community. Each room has an emergency pull alarm, which transmits audio and visual signal to monitors in medication room and front desk. Thirty apartments are inspected. Common areas include lobby, sun room, dining room and expansive outdoor space, which includes level patio. There is one elevator and 5 interior stairwells, plus 2 exterior fire exit stairs. There are no accessible bodies of water or fire safety hazards observed. Medications are stored in locked medication room on 2nd floor and chemicals are stored in locked rooms. A comfortable temperature is maintained and passageways are clear.
Hot water temperature checked in 3 rooms and common bathroom within range of 105 - 120 degrees F.
There are at least 16 full bathrooms that are equipped with grab bars and nonskid flooring material. PPE supplies are maintained. Food supply and first-aid kit are inspected.
Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Food service staff have current safe food handling certifications, including food and beverage director. Quarterly reviews are completed by a registered dietician and reports are maintained; copies of last 2 reports are given to LPA. Gregory Bogart is a certified RCFE administrator (x 5/24 that oversee facility operations. Some client medications records are reviewed.

Staff records, including training, will be reviewed at a later date.

The following information is requested to be submitted to CCL by 4/23/24

- Proof of current liability insurance (including coverage limits)
- Proof of control of property (signed lease agreement)
- LIC 309 Administrative Organization

Deficiency of the California Code of Regulations, Title 22 is cited today. Also see Technical Advisory Notes--6 pages. Annual inspection to be completed at a later date.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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 Has Been Signed on 04/16/2024 05:53 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(26
FOOD SERVICE
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of nonperishable food supply, the licensee did not comply with the section cited above, as there is an insufficient 7-day canned food supply, which poses a potential health, safety or personal rights risk to persons in care.
Seven-day food supply consists of 2 large cans of ravioli, 23 cans of pineapple, 22 cans of sauerkraut.
POC Due Date: 04/23/2024
Plan of Correction
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Receipt for purchase of 7-day supply of canned fruit, vegetables and protein to be sent to CCLD BY DUE DATE.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/16/2024
LIC809 (FAS) - (06/04)
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