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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601045
Report Date: 12/20/2022
Date Signed: 12/20/2022 12:09:56 PM


Document Has Been Signed on 12/20/2022 12:09 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:PORTOLA GARDENSFACILITY NUMBER:
385601045
ADMINISTRATOR:MINDY HANFACILITY TYPE:
740
ADDRESS:350 UNIVERSITY STTELEPHONE:
(415) 337-1587
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94134
CAPACITY:132CENSUS: 64DATE:
12/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Administrator, Mindy Han TIME COMPLETED:
12:18 PM
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On December 20, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that was reported to CCLD on December 2, 2022. LPA met with Administrator, Mindy Han and explained the purpose of the visit.

The facility reported on November 27, 2022, Resident #1 (R1) eloped from the facility. During the visit, LPA reviewed R1's file and spoke to Administrator. According to the file reviewed, R1 has a diagnosis of dementia and unable to leave the facility unassisted.

According to the Administrator, R1 was last seen in his room during a routine check at 2:40pm. At around 3:40pm, staff observed R1 was not in his/her room or in the community. Staff searched the facility grounds for R1. R1 returned back to the community at 4pm accompanied by a paramedic who observed R1 walking around the neighborhood.
R1 did not have any injuries noted. According to the Administrator, after this incident, all required parties were notified and a private caregiver was assigned to R1 until R1 moves into a more secure environment.

Based on interviews and file reviewed during the visit, the facility did attempt to ensure basic services were being met for R1. No citations will be issued at this time.

Report is reviewed with Administrator, Mindy Han 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: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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