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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601115
Report Date: 10/03/2024
Date Signed: 10/03/2024 10:48:03 AM

Document Has Been Signed on 10/03/2024 10:48 AM - 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:GORDON MANORFACILITY NUMBER:
415601115
ADMINISTRATOR/
DIRECTOR:		GADDI, PORTIAFACILITY TYPE:
740
ADDRESS:1616 GORDON STREETTELEPHONE:
(650) 562-0555
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 82CENSUS: 69DATE:
10/03/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Portia Gaddi, Administrator and John Solano, Infection Preventionist TIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 October 3, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 AM to conduct a Case Management visit in regards to an incident that occurred on 9/14/2024 and reported by the licensed facility, in which a resident had an un-witnessed fall. LPA Calandra was greeted by Portia Gaddi, Administrator and explained the purpose of the facility. John Solano, Infection Preventionist, arrived later during the visit.

LPA Calandra gathered and reviewed the LIC 602, care plan, etc. and conducted interviews. Based on review of documents and interviews, LPA Calandra found that staff responded in a timely manner, notified the appropriate parties and updated R1's needs and services plan.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Portia Gaddi, Administrator and John Solano, Infection Preventionist and a copy of the report left at the facility.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 1