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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 07/15/2024
Date Signed: 07/15/2024 04:46:06 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 07/15/2024 04:46 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
SAN BRUNO RO, 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: 89DATE:
07/15/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Greg Bogart and Navi KaurTIME COMPLETED:
04:45 PM
NARRATIVE
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To complete annual inspection of 4/16/24, LPA Jeung reviewed client and staff records.

Deficiencies of the California Code of Regulations, Title 22, are cited on following pages, per observations made on 4/16/24 and today.


SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
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 07/15/2024 04:46 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
HSC
1569.311

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Every RCFE shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The Dept. shall account for the presence of these detectors during inspections. This requirement was not met,
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Plan/proof of correction for installation of carbon monoxide detectors will be sent to CCLD BY DUE DATE
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as carbon monoxide detectors were not present on 4/16/24, per administrator. This poses a potential health and safety risk for clients in care.
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Type B
07/29/2024
Section Cited
CCR87307(c)

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PERSONAL ACCOMMODATIONS & SERVICES
Individual privacy shall be provided in all toilet, bath and shower areas.
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Plan/proof of correction for removal of commodes in shared rooms will be sent to CCLD BY DUE DATE
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This requirement was not met, as commodes were observed on 4/16/24 in shared rooms 103, 107, 116. This poses a potential health, safety, or personal rights risk to clients in care.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/15/2024 04:46 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/29/2024
Section Cited
CCR
87608(a)(3)

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POSTURAL SUPPORTS
A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order.
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MD orders for half bed rails for clients #2 & #8 will be sent to CCLD. MD orders should be maintained for all clients who use half bed rails.
Plan/proof of correction to be sent to CCLD BY DUE DATE
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This requirement is not met, as MD orders are not maintained for half bed rails for 2 clients, which poses a potential health, safety or personal rights risk to clients. Clients #2 & #8 are missing MD orders for half bed rails. On 4/16/24, half bed rails observed for 20 beds, which require MD orders on file.
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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: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024
LIC809 (FAS) - (06/04)
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