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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 06:04:01 PM


Document Has Been Signed on 03/03/2022 06:04 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 - IncidentUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:LVN Joy Galimba and consultant Monica SantosTIME COMPLETED:
06:00 PM
NARRATIVE
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In the absence of administrator, LPA Jeung met with acting care coordinator and consultant regarding incident reported today to CCLD. Client #1 was admitted yesterday, 3/2/22, and is non-ambulatory per MD report, as well as unable to leave facility unassisted and unable to bathe, dress, feed self or care for toileting needs. MD report and other relevant documents for client #1 are provided to LPA today. According to Ms. Santos, client was admitted for a 30 day respite paid for by Kaiser Hospital.
LPA observed location of room where client slept last night, and noted 2 exits nearby. One exit door emitted a loud alarm, and the other emitted a low volume audible alarm. Both alarms ceased when exit doors were closed. Staff do not have to physically respond to alarm to turn it off.

Deficiency of the CA Code of REgulations, Title 22 is cited on a following page.

During this visit, LPA was requested by the CCLD Investigation Branch to inquire about another client. LPA reviewed file for client #2, who moved out of facility on 3/1/22.
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)
Page: 1 of 2


Document Has Been Signed on 03/03/2022 06:04 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/04/2022
Section Cited

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BASIC SERVICES
Basic services shall at a minimum include:
Care and supervision, meaning the responsibility for... ongoing assistance with ADLs, without which the resident’s physical health, mental health, safety, or welfare would be endangered.
This requirement was not met, as client #1
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eloped from facility without staff knowledge today. Because Licensee failed to ensure that client was supervised, he left the premises, which posed a immediate risk to his health, safety and welfare.
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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 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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
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