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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 03/03/2022
Date Signed: 03/03/2022 05:49:31 PM


Document Has Been Signed on 03/03/2022 05:49 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: 70DATE:
03/03/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:LVN Joy Galimba and consultant Monica SantosTIME COMPLETED:
06:00 PM
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During complaint visit, LPA Jeung toured facility and observed the following:

- COVID isolation room is not identified as such by signage
-- COVID sign should be posted on isolation room
- Isolation cart with PPE is not set up outside of isolation room
-- PPE should be stored in isolation cart outside of isolation room
- Handwashing reminder signs are not posted at each sink in public bathrooms where people wash their hands
-- Handwashing reminder signs should be posted at each sink in public bathrooms, not just outside of bathrooms

LPA reminded Ms. Galimba to refer to protocols identified in facility's COVID Mitigation Plan.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
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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