<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601058
Report Date: 09/23/2024
Date Signed: 09/23/2024 01:58:39 PM

Document Has Been Signed on 09/23/2024 01:58 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PORTOLA PLACEFACILITY NUMBER:
415601058
ADMINISTRATOR/
DIRECTOR:		ATIENZA, ARMANDFACILITY TYPE:
740
ADDRESS:445 PORTOLA DRIVETELEPHONE:
(650) 349-1755
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
09/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Administrator - Armand AtienzaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 09/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with caregivers Tracy Byrne and Jeremiah Ricarto. LPA spoke to the licensee Armand Atienza via telephone during today's inspection. LPA explained the purpose of today's visit to the caregivers present. There are 2 caregivers in the facility and 6 residents present.

This is a two level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There are no hospice residents as of today's inspection visit. The second level of the facility is occupied by private renters. There is no access from the second floor into the facility. There is a separate entrance for that second floor unit located near the garage of the facility. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. The floors of the facility are observed to be sticky to foot wear making an audible sticking sound through out. LPA observed spots and areas around the bathroom and resident rooms where the flooring appear to be dirty in some areas with visible marks and debris. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is in good repair. Knives are stored and locked per observation made. Perishable and non-perishable food supply in place. There is an additional refrigerator/ freezer in the garage area which carries additional food supplies for resident use. Also in the garage is the laundry area and where the cleaning supplies are primarily stored. LPA also observed cleaning supplies locked beneath the kitchen sink. First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet adjacent to the refrigerator. LPA observed at least one fire extinguisher in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating.

Continued on next...
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058
VISIT DATE: 09/23/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Page 2

Facility is not equipped with fire sprinklers. LPA also observed fire pull stations in the rear and front of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature is measured at 123F and increasing during today's inspection. This poses an immediate health and safety risk to resident in care. Also observed in the bathroom is a common hand towel for resident use to use for drying of hands. LPA provided advisory notice that such should not be in place for resident use in order to prevent the spread of illness and other reasons. Linen supplies are observed as in place in a hallway closet. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. LPA did observe in a resident's half bath in their room a shelf above the toilet that is broken off the wall and resting on top of the toilet. Shower floor is equipped with non-skid mat for resident use. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 6 resident files. R1 and R4 physician's report is not current to within one year and has a dementia diagnosis. This poses an immediate health and safety risk to the resident in care. Staff files are reviewed and are current. Administrator certificate is observed as expired as of 06/15/2024. LPA is requesting an updated copy to be sent to the Department for review.

The following updated forms are requested to be submitted to CCLD by 09/30/2024:

• Copy of all updated administrator certificates
• Copy of facility's liability insurance
• LIC308 Designation of responsible staff person
• LIC610E Emergency Disaster Plan
• LIC500 Staff Schedule
• Copy of control of property or copy of lease

Citations are issued on this day on the attached LIC809D pages. Technical violations and Technical Assistance also provided on this day on the attached LIC9102 forms. Report is reviewed with Jeremiah and Tracy and a copy of report is provided.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 09/23/2024 01:58 PM - It Cannot Be Edited


Created By: Jaime Vado On 09/23/2024 at 12:39 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/24/2024
Section Cited
CCR
87303(e)(2

1
2
3
4
5
6
7
87303(e)(2) Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee shall develop a plan to lower the water temperature thorough out the facility, monitor, and log water temperature to ensure that the temperature is within 105F and 120F at all times.
8
9
10
11
12
13
14
Based on facility observations made during water temperature testing, LPA found that the water temperature in the common bathroom for the facility, the water temerature was tested at 123F and increasing. This poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type A
09/24/2024
Section Cited
CCR87705(c)(5)

1
2
3
4
5
6
7
87705(c)(5) Care of Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by:
1
2
3
4
5
6
7
Licensee shall develop a plan to maintain all residents with dementia physician's reports to be kept up to date annually. Report and evidence of R1's updated physician's report to be sent to the department.
8
9
10
11
12
13
14
Based on records reviewed, LPA observed that the physician's report for R1 is not current. Residents with dementia require a new physicians report annually. This poses an immediate health and safety risk to resident in care.
8
9
10
11
12
13
14
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:April Cowan
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 09/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/23/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3