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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 03/03/2022
Date Signed: 03/08/2022 12:29:56 PM

Unfounded


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
09/16/2021 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210916092205
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
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Joy Galimba and consultant Monica SantosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Resident was physically abused
- Staff is not allowing visitors
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Based on information obtained and investigation by LPA Jeung, these allegations are determined to be unfounded, meaning that the allegations could not have happened and/or are without a reasonable basis. Furthermore, despite multiple requests, complainant has failed to provide evidence to support these allegations.

On 8/25/21, the Dept. investigated and concluded that a fall event regarding the hospice resident on 7/19/21 was unsubstantiated. This complaint alleges that the resident sustained injuries caused by a physical assault. Information obtained from prior investigation and this investigation--including medical records and interviews with medical professionals who attended resident--indicate that resident sustained injuries that were consistent with a mechanical fall forward, including facial bleeding and bruising. There was no suspicion that resident was assaulted.
There is no indication that visitors were not allowed to visit resident based on review of facility visitor logs for July, August, September 2021 and information obtained from staff interviews. During a visit from a relative of this same resident who was verbally disruptive, SFPD were called to respond.


Unfounded
Estimated Days of Completion:
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.
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
09/16/2021 and conducted by Evaluator Audrey Jeung
COMPLAINT CONTROL NUMBER: 14-AS-20210916092205

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
UNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Joy Galimba and consultant Monica SantosTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Staff did not assist the resident with incontinence
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
There is no indication from medical records and facility records to suspect that staff neglected to care for client's incontinence needs. On 8/25/21, the Dept. investigated and was unable to conclude that this resident was left in soiled diapers for an extended period of time.

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 allegation is UNSUBSTANTIATED.
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 2 of 2