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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 12/15/2021
Date Signed: 12/15/2021 02:00:25 PM

Document Has Been Signed on 12/15/2021 02:00 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PORTOLA GARDENSFACILITY NUMBER:
385601045
ADMINISTRATOR:JEFFREY DILLONFACILITY TYPE:
740
ADDRESS:350 UNIVERSITY STTELEPHONE:
(415) 337-1587
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY: 132CENSUS: DATE:
12/15/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director of Resident Care, Ivan EmilianoTIME COMPLETED:
02:15 PM
NARRATIVE
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On December 15, 2021, Licensing Program Analyst (LPA) Komal Charitra and Audrey Jeung conducted an unannounced Case Management visit regarding an incident that occurred on December 8, 2021 and was not reported to Licensing as required. LPAs were greeted by Director of Resident Care, Ivan Emiliano and Administrator, Jeffrey Dillon joined shortly thereafter. LPAs explained the purpose of the visit. During today's visit, LPAs reviewed R1's file.

On December 8, 2021, Resident (R1) left the facility and is still missing. According to the LVN, R1 is independent and able to leave the facility unassisted. However, LPAs received written order from R1's MD, dated 12/1/21 stating that R1 is unable to leave the facility unsupervised. Facility LVN denies knowledge of this order nor receipt. Additional information is required.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE: DATE: 12/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/15/2021 02:00 PM - It Cannot Be Edited

Citations on this Visit Report are Under Appeal!


Created By: Komal Charitra On 12/15/2021 at 12:14 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
12/22/2021
Section Cited
CCR
87463(a)

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Reappraisal: The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition.
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Plan of care to be developed for R1 to include his unusual behaviors. Copy to be submitted to CCLD by 12/22/2021.
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This requirement is not met as Licensee failed to appraise R1 after several unusual incidents; 12/8/21, 9/7/21,11/20/20, and 3/28/20, some of which required medical intervention. Licensee failed to ensure that appraisal and care plan accurately reflects his needs. This poses a potential health and safety risk to client.
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Under Appeal
Type B
12/22/2021
Section Cited
CCR87211(a)(2)

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Reporting; Occurrences, such as...or major accidents which threaten the welfare, safety or health of residents...shall be reported within 24 hours... to the licensing agency
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Administrator to submit acknowledgement of Title 22 Regulations for prompt reporting of threats to client's health, safety, or welfare by 12/22/2021.
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This requirement was not met as R1 left the facility on 12/8/21 without staff knowledge and Licensee failed to report this to CCLD as required. Incident report was submitted following LPA's reqeust and contact with facility LVN on 12/10/21. This posed a potention health, safety, and personal rights risk to clients 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:Julio Montes
LICENSING EVALUATOR NAME:Komal Charitra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2021


LIC809 (FAS) - (06/04)
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