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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601045
Report Date: 10/11/2022
Date Signed: 10/11/2022 11:11:49 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
12/21/2021 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211221110610
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: 63DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Mindy HanTIME COMPLETED:
11:17 AM
ALLEGATION(S):
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9
Neglect/Lack of Supervison - Client was injured after leaving the facility unassisted
INVESTIGATION FINDINGS:
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13
On October 11, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Mindy Han and Regional Business Development, Jeffrey Dillon and explained the purpose of the visit.

Regarding the allegation, neglect/ lack of supervision—client was injured after leaving the facility unassisted, according to the complainant, on September 7, 2021, Resident #1 (R1) was found at the park rolling around naked in the bushes by San Francisco Police Department (SFPD). In addition, it was indicated that R1 was found with scratches and blood all over his body. During the investigation, LPA interviewed staff and reviewed documentation collected. Interviewed staff indicated that when R1 was returned to the facility on 9/7/2021 by SFPD, the facility staff observed lacerations on face, torso, bilateral legs, and bilateral arms which the facility staff treated immediately. In addition, R1 was never taken to the ER after being assessed by both the EMT’s and facility staff. Furthermore, interviewed staff indicated R1 was alert and oriented. According to the physician report dated January 19, 2018, R1 has a diagnosis of Parkinsons, however, was able to leave the facility unassisted.

CONT. to 9099C

CONT. to 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
12/21/2021 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20211221110610

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: 63DATE:
10/11/2022
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Administrator, Mindy HanTIME COMPLETED:
11:17 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to evaluate resident after several AWOLs and SFPD intervention
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On October 11, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Administrator, Mindy Han and Regional Business Development, Jeffrey Dillon and explained the purpose of the visit.

Regarding the allegation, facility staff failed to evaluate resident after several AWOLs and SFPD interventions, according to the complainant, resident #1 (R1) has a history of going to the park and rolling around the bushes naked. During the investigation, according to interviewed staff, although R1 would leave the facility, he/she would always return back to the facility within hours which indicates R1 has never AWOL’d. In addition, interviews indicated that there were no prior SFPD interventions prior to the incident that occurred on 9/7/2021.

Based on the above information, the Department has found that this allegation to be UNFOUNDED, meaning that this allegation was false, could not have happened and/or is without a reasonable basis.

Report is reviewed with Administrator, Mindy Han and Regional Business Development, Jeffrey Dillon and a copy is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
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 3
Control Number 14-AS-20211221110610
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PORTOLA GARDENS
FACILITY NUMBER: 385601045
VISIT DATE: 10/11/2022
NARRATIVE
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In addition, file reviewed indicated that the facility had a written fax order from the Neurologist dated 4/9/2021 indicating that R1 may leave the facility by himself unless he/she appeared confused, drowsy, or unsteady. Although R1 sustained injuries after leaving the facility unassisted, there is no evidence of neglect or lack of supervision as R1 was able to leave the facility unassisted per doctor’s orders.

Therefore, based on the information collected, and interviews, the allegation that Neglect/Lack of Supervision - client was injured after leaving the facility unassisted UNSUBSTANTIATED, meaning that although the allegation may have happened or is valid, there is no preponderance of evidence to prove that the alleged violation occurred.

Report is reviewed with Administrator, Mindy Han and Regional Business Development, Jeffrey Dillon and a copy is provided.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3