385601045-8-25-2021-14-AS-KHOS-C6FK5C-20210901073542

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:51:56 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
07/23/2021 and conducted by Evaluator Mohamed Filouane

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210723151722

FACILITY NAME:	PORTOLA GARDENS		FACILITY NUMBER:	385601045
ADMINISTRATOR:	JEFFREY DILLON		FACILITY TYPE:	740
ADDRESS:	350 UNIVERSITY ST		TELEPHONE:	(415) 337-1587
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94134
CAPACITY:	132	CENSUS: 65	DATE:	08/25/2021
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Jeffrey Dillon		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Resident fell while in care sustaining injuries.
Staff left resident in soiled diapers for extended period of time resulting in bladder infection.
Facility is not answering their phones.
Residents wheelchair is in disrepair.

INVESTIGATION FINDINGS:

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On 8/25/21, Licensing Program Analyst (LPA) Mohamed Filouane conducted a follow-up visit regarding this complaint investigation. LPA Filouane spoke to Administrator Jeffrey Dillon, explained the purpose of the visit, and then delivered the findings.

Concerning the allegation of the resident falling while in care and sustaining injuries, LPA Filouane interviewed the Administrator, and Director of Wellness, as well as reviewed the incident report submitted to the Community Care Licensing Division. This incident involving the resident occurred as an unwitnessed fall, which led to a hospital visit on 07/18/21. Facility staff believe the resident had tried to push themselves off the bed and to their walker. There is no violation under Title 22 regulations for an unwitnessed fall. After review, this allegation is unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20210723151722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA GARDENS	FACILITY NUMBER: 385601045
	VISIT DATE: 08/25/2021

NARRATIVE

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Concerning the allegation of staff having left the resident in soiled diapers which resulted in a bladder infection during the 07/19/21 hospital visit, LPA Filouane interviewed the Administrator, Director of Wellness, as well as reviewed the medical discharge document of the resident on 07/19/21. The Administrator and Director of Wellness denied this allegation. The Administrator stated there is no record of soiled diapers or a bladder infection regarding the resident in question. After review, this allegation is unsubstantiated.

Concerning the allegation of the facility not answering their phones, LPA Filouane tested the facility phone line before conducting the 10-day visit, as well as tested the facility phone line during the 10-day visit. Facility staff answered both unannounced calls. The Administrator stated the facility's phone line had days when it was working and not working in past weeks. After review, this allegation is unsubstantiated.

Concerning the allegation of the resident's wheelchair is in disrepair, LPA Filouane interviewed the Administrator, Director of Wellness, reviewed resident's record, and toured the resident's room. The Administrator denied the allegation. The Administrator stated the resident used their walker. The Director of Wellness stated they had never seen the resident use their wheelchair. LPA observed the wheelchair as functioning and not in disrepair. After review, this allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations is UNSUBSTANTIATED.

Exit interview conducted with the Administrator. The Administrator will receive this LIC9099 report through email to sign. The Administrator will then email the signed version back to the LPA.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed Filouane	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021

LIC9099 (FAS) - (06/04)

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