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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 03/25/2022
Date Signed: 03/25/2022 11:31:13 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
08/31/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210831121226
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:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Abella TolmasoffTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide adequate supervision
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1100 hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations received. LPA met with LVN Abella Tolmasoff and explained purpose of todays visit.

During the course of the investigation it was found through interviews that there were at least four residents present as well as two staff. One of the caregivers was present at time of fall while the other was the receptionist but was not able to visually supervise residents as she was on the telephone in an office adjacent to the lobby where the resident fell. Interviews conducted identified that there is always a minimum of two staff present in the lobby for supervision and this ratio increases if there are more residents present. This allegation is unfounded.

This agency has investigated the complaint alleging that taff did not provide adequate supervision. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No citations issued. Report discussed with Abella Tolmasoff.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
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
08/31/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210831121226

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:
03/25/2022
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Abella TomasoffTIME COMPLETED:
12:15 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Questionable death
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day at 1100 hours, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegations received. LPA met with Abella Tolmasoff and explained purpose of todays visit.

During the course of the investigation it was found through interviews and 911 records reviewed that the death of the resident was observed as a fall. The resident was observed by staff present that the resident stumbled and fell backward hitting his head. No one touched the resident to cause the fall. Staff assessed the resident and called 911. Upon instructions from 911 operator it was advised to begin CPR but this did not start until approximately for six minutes after 911 was called. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2