Inspection Reports for Portola Gardens
350 University St, San Francisco, CA 94134, United States, CA, 94134
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with several complaint investigations unsubstantiated. However, some reports did cite deficiencies related primarily to resident rights, supervision, and documentation, including failure to provide dignity in resident interactions, inadequate supervision leading to harm, and missing or outdated physician orders. The most recent report from July 18, 2025, substantiated a violation for not according a resident dignity in their relationships with staff and others, while other allegations in that visit were unsubstantiated. Earlier investigations found issues such as inappropriate staff conduct and failure to meet hygiene needs, but no fines, license suspensions, or enforcement actions were listed in the available reports. The facility’s record shows some recurring concerns around personal rights and supervision, with no clear pattern of improvement or decline over time.
Deficiencies per Year
4
3
2
1
0
High
Moderate
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Capacity: 104
Deficiencies: 1
Jul 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint received on 2025-05-02 regarding allegations of resident dignity violations and denial of rights.
Findings
The investigation substantiated that a resident was not accorded dignity in their relationship with staff and other residents, constituting a violation of residents’ personal rights. Another allegation that a resident was denied the right to file a complaint was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for the allegation that a resident was not accorded dignity in their relationship with staff and other residents. The allegation that a resident was denied the right to file a complaint was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall be accorded dignity in their personal relationships with staff and residents. | Type B |
Report Facts
Capacity: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yi Sam Jian | Licensing Program Analyst | Conducted the complaint investigation |
| Gregory K Bogart | Administrator | Facility administrator present during the investigation |
| Lea Salazar | Staffing Coordinator | Interviewed during the complaint investigation |
| April Cowan | Licensing Program Manager | Named in report as licensing program manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 104
Deficiencies: 0
Jul 18, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2025-06-03 regarding allegations that the facility did not allow residents to have visits.
Findings
The investigation found no evidence to support the allegation that residents were denied visits. Resident interviews indicated visitation was not denied. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility did not allow residents to have visits. The investigation was unannounced and conducted by Licensing Program Analyst Yi Sam Jian. The allegations were unsubstantiated.
Report Facts
Capacity: 104
Census: 92
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yi Sam Jian | Licensing Program Analyst | Conducted the complaint investigation |
| Gregory K Bogart | Administrator | Facility administrator present during the investigation |
| Lea Salazar | Staffing Coordinator | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 90
Capacity: 104
Deficiencies: 0
May 28, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-05-23 regarding staff not ensuring a comfortable environment for residents.
Findings
The investigation found that the reported noise was temporary and related to essential maintenance work during sprinkler system installation. Earplugs were provided to residents, no verified harm or medical attention was required, and no additional formal complaints were found. The allegations were unsubstantiated.
Complaint Details
The complaint alleged that staff did not ensure a comfortable environment was provided for residents. The allegations were investigated and found to be unsubstantiated due to lack of preponderance of evidence.
Report Facts
Complaint Control Number: 14
Capacity: 104
Census: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yi Sam Jian | Licensing Program Analyst | Conducted the complaint investigation visit |
| Gregory K Bogart | Administrator | Facility administrator met during investigation |
| Navpreet Kaur | Health and Wellness Director | Met during investigation and involved in discussion of findings |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 104
Deficiencies: 2
Apr 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted following a complaint received on 2025-01-24 regarding allegations of resident injury due to lack of supervision and failure to conduct resident reappraisal after significant changes.
Findings
The investigation substantiated that the facility failed to adjust care and supervision to prevent harm to other clients and did not conduct required reappraisals after documented incidents of harm. Another allegation regarding false claims to the Licensing Department was found unsubstantiated.
Complaint Details
The complaint investigation was substantiated for allegations that a resident sustained injury due to lack of supervision and failure to conduct reappraisal after significant changes. The allegation of false claims or misleading statements to the Licensing Department was unsubstantiated.
Severity Breakdown
Type A: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Personal rights requirement: To care, supervision, and services that meet their individual needs was not met as care and supervision were not adjusted to prevent harm to other clients despite documented incidents. | Type A |
| Reappraisals requirement: The reappraisal shall document significant changes in behavioral expression that may result in harm to self or others was not met as the client was not reappraised after documented incidents of harm to staff. | Type A |
Report Facts
Capacity: 104
Census: 92
Deficiency count: 2
Plan of Correction Due Date: Apr 25, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yi Sam Jian | Licensed Program Analyst | Conducted the complaint investigation and delivered findings |
| Gregory K Bogart | Administrator | Facility administrator involved in the investigation |
| April Cowan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 92
Capacity: 104
Deficiencies: 2
Apr 24, 2025
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 2024-12-05 regarding inappropriate staff behavior and failure to meet resident hygiene needs.
Findings
The investigation substantiated allegations that staff engaged in inappropriate sexual behavior in a resident's room and failed to meet a resident's hygiene needs as per the service plan. Other allegations regarding safeguarding belongings and facility cleanliness were unsubstantiated.
Complaint Details
The complaint investigation was substantiated based on video evidence and documentation review. The allegations of inappropriate sexual behavior and failure to meet hygiene needs were found to be valid. Other allegations about safeguarding belongings and facility odor were unsubstantiated.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Staff engaged in inappropriate conduct inside the resident’s room, violating personal rights and posing an immediate health and safety risk. | Type A |
| Facility staff failed to meet resident hygiene needs as documented bathing assistance was not provided according to the service plan. | Type B |
Report Facts
Capacity: 104
Census: 92
Deficiencies cited: 2
Plan of Correction Due Date: Apr 25, 2025
Plan of Correction Due Date: Apr 29, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Yi Sam Jian | Licensed Program Analyst | Conducted the complaint investigation and delivered amended LIC9099 |
| Gregory K Bogart | Administrator | Facility administrator met with investigator and agreed to submit plans of correction |
| April Cowan | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 91
Capacity: 104
Deficiencies: 0
Mar 28, 2025
Visit Reason
An unannounced case management visit was conducted regarding an incident report of a care partner allegedly making a sexual comment to a resident.
Findings
The Licensing Program Analyst confirmed the incident with the resident and interviewed the administrator, who stated the care partner involved is no longer employed. The facility was instructed to provide staff training documentation by 04/08/2025.
Complaint Details
Complaint involved an alleged sexual comment made by a care partner to resident R1. The care partner was employed for two weeks and is no longer employed at the facility.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident. |
| Yi Sam Jian | Licensing Program Analyst | Conducted the unannounced case management visit and investigation. |
Inspection Report
Annual Inspection
Census: 92
Capacity: 104
Deficiencies: 1
Feb 25, 2025
Visit Reason
The inspection was an unannounced required 1 year annual inspection visit conducted to evaluate compliance with regulations.
Findings
The facility was toured and inspected, including apartments, common areas, medication storage, and staff records. Deficiencies were cited related to missing physician orders for half bed rails for 4 clients, posing potential health and safety risks.
Deficiencies (1)
| Description |
|---|
| MD orders for half bed rails were not maintained for 4 clients, posing a potential health, safety, or personal rights risk. |
Report Facts
Clients missing MD orders for half bed rails: 4
Total residents reviewed for deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Facility Administrator present during inspection and report review |
| Navpreet Kaur | Health and Wellness Director | Met with Licensing Program Analysts and explained purpose of visit |
| Yi Sam Jian | Licensing Program Analyst | Conducted inspection and signed report |
| Andrea Medlin | Licensing Program Manager | Supervised inspection and named in report |
Inspection Report
Census: 91
Capacity: 104
Deficiencies: 0
Jan 7, 2025
Visit Reason
The visit was an unannounced case management inspection to follow up on multiple changes within the facility, including an increase in capacity request and a change of license.
Findings
The Licensing Program Analyst toured the facility and inspected resident bedrooms related to the capacity increase request, found no concerns or overcapacity in non-ambulatory and bedridden areas, and noted no deficiencies during the visit. Plans for a fire inspection and change of ownership were discussed.
Report Facts
Resident census: 91
Total capacity: 104
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Executive Director | Met with Licensing Program Analyst during inspection and discussed facility changes |
| Dominic Tobola | Licensing Program Analyst | Conducted the inspection visit |
| Andrea Medlin | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 89
Capacity: 132
Deficiencies: 3
Jul 15, 2024
Visit Reason
To complete the annual inspection of 4/16/24, the Licensing Program Analyst reviewed client and staff records and conducted an unannounced visit on 07/15/2024.
Findings
Deficiencies were cited related to the absence of carbon monoxide detectors, lack of individual privacy in shared rooms due to commodes, and missing physician orders for postural supports (half bed rails) for certain clients, posing potential health, safety, or personal rights risks.
Severity Breakdown
Type B: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Carbon monoxide detectors were not present as required, posing a potential health and safety risk. | Type B |
| Individual privacy was not provided in all toilet, bath, and shower areas; commodes were observed in shared rooms 103, 107, and 116. | Type B |
| Missing physician orders for postural supports (half bed rails) for clients #2 and #8; half bed rails observed for 20 beds require MD orders on file. | Type B |
Report Facts
Deficiencies cited: 3
Census: 89
Total Capacity: 132
Beds requiring MD orders: 20
Clients missing MD orders: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator/Director | Named in relation to carbon monoxide detector deficiency |
| Audrey Jeung | Licensing Program Analyst | Conducted inspection and signed report |
| April Cowan | Licensing Program Manager | Supervisor overseeing inspection |
Inspection Report
Census: 81
Capacity: 132
Deficiencies: 1
Apr 16, 2024
Visit Reason
The visit was a required, unannounced one-year inspection of the Portola Gardens facility to evaluate compliance with regulations.
Findings
The facility was toured and inspected, noting the presence of emergency alarms, medication storage, and safety features. A deficiency was cited related to insufficient nonperishable food supply, specifically an inadequate 7-day canned food supply. The annual inspection is to be completed at a later date.
Deficiencies (1)
| Description |
|---|
| Insufficient 7-day canned food supply, posing a potential health, safety or personal rights risk to persons in care. |
Report Facts
Census: 81
Total Capacity: 132
Food supply counts: 2
Food supply counts: 23
Food supply counts: 22
Plan of Correction Due Date: Apr 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Facility administrator overseeing operations |
| Cara Smith | Licensing Program Manager | Named in relation to the inspection and deficiency oversight |
| Audrey Jeung | Licensing Program Analyst | Conducted the facility evaluation and signed the report |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 132
Deficiencies: 0
Jan 18, 2024
Visit Reason
An unannounced complaint investigation visit was conducted in response to an allegation that staff were sleeping during their shifts at the facility.
Findings
The investigation found no evidence to substantiate the allegation that staff were sleeping during their shifts. Interviews with the administrator, assistant administrator, staff, and residents did not confirm the complaint, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged that two staff members on the night shift were sleeping in chairs during their shifts. After interviews and investigation, the allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 132
Census: 80
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Met with Licensing Program Analyst during the investigation |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cara Smith | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 80
Capacity: 132
Deficiencies: 1
Jan 18, 2024
Visit Reason
An unannounced case management visit was conducted in relation to complaint control #14-AS-20231227095941 to investigate resident concerns about staff response times to call buttons at night.
Findings
The investigation found that 4 out of 5 residents reported staff did not respond or responded late to call buttons at night, and the facility was unable to provide documentation showing timely staff response. A deficiency was cited under Residential Care Elderly California Code of Regulations, Title 22, Division 6.
Complaint Details
The visit was complaint-related with complaint control #14-AS-20231227095941. The complaint was substantiated based on resident interviews and lack of timely response documentation.
Deficiencies (1)
| Description |
|---|
| Based on resident interviews, 4/5 residents indicated that when they tried to press their call pendants/buttons, staff either did not respond or did not respond in a timely manner, posing an immediate health and safety risk. |
Report Facts
Residents interviewed: 5
Residents reporting delayed/no response: 4
Facility census: 80
Facility capacity: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Met with Licensing Program Analyst during the visit and named in the report |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Cara Smith | Licensing Program Manager | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 75
Capacity: 132
Deficiencies: 0
Dec 11, 2023
Visit Reason
The visit was conducted in response to Suspected Abuse Reports (SOC341) submitted on 12/1/23 and 12/6/23, involving incidents with three clients. The purpose was to discuss incidents, obtain updates, review client files, and interview clients and staff.
Findings
The facility reported a gastrointestinal outbreak and received recommendations from the San Francisco Department of Public Health. The administrator was reminded to ensure all resident appraisals and care plans are signed. No deficiencies were observed at the time of the visit.
Complaint Details
The complaint investigation involved suspected abuse reports submitted on 12/1/23 and 12/6/23 concerning three clients. The administrator was instructed to submit detailed Incident Reports by 12/12/23. The facility also reported a gastrointestinal outbreak to public health authorities.
Report Facts
Facility capacity: 132
Resident census: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Gregory K Bogart | Administrator | Met with Licensing Program Analyst to discuss incidents and updates |
| Audrey Jeung | Licensing Program Analyst | Conducted interviews, reviewed files, and obtained recommendations |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 72
Capacity: 132
Deficiencies: 0
Sep 29, 2023
Visit Reason
An unannounced complaint investigation visit was conducted to investigate allegations received regarding resident care issues including hydration, feeding, hygiene, medical condition changes, and infection control procedures.
Findings
The investigation found conflicting information between the allegations and facility interviews, observations, and documentation. There was insufficient evidence to substantiate the allegations, resulting in an unsubstantiated finding.
Complaint Details
The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.
Report Facts
Capacity: 132
Census: 72
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation |
| Lea Salazar | Administrative Assistant | Met with Licensing Program Analyst during investigation |
| Jeffrey Dillon | Administrator | Facility administrator named in report header |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 69
Capacity: 132
Deficiencies: 0
Aug 30, 2023
Visit Reason
An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements.
Findings
The facility was found to be in good repair with adequate safety measures, proper food storage, and updated resident and staff records. No deficiencies were cited during the inspection.
Report Facts
Capacity: 132
Census: 69
Food storage duration: 2
Food storage duration: 7
Fire extinguisher check date: Jun 8, 2023
Staff training hours: 20
Water temperature: 110
Facility temperature: 78
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst | Conducted the inspection and authored the report |
| Lea Salazar | Administrative Assistant | Met with the Licensing Program Analyst during the inspection |
| Gregory K Bogart | Administrator | Facility administrator named in the report |
| Jackie Jin | Licensing Program Manager | Named in the report |
Inspection Report
Complaint Investigation
Census: 69
Capacity: 132
Deficiencies: 1
Apr 3, 2023
Visit Reason
The inspection was an unannounced 10-day complaint investigation visit triggered by allegations regarding staff not repairing a resident's medical bed and not properly positioning a resident while in care.
Findings
The investigation substantiated that staff did not repair Resident 1's medical bed, which was broken due to a non-working electrical outlet, but was observed to be in good repair during the visit. The allegation that staff did not properly position the resident was unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that staff did not repair a resident's medical bed while in care. The allegation that staff did not properly position a resident while in care was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| 87303 Maintenance and Operation: The facility shall be clean, safe, sanitary and in good repair at all times. The electric hospital bed was broken due to a non-working electrical outlet. | Type B |
Report Facts
Capacity: 132
Census: 69
Deficiency due date: Apr 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Dillon | Administrator | Met with Licensing Program Analyst during investigation and acknowledged findings |
| Renafe Mosquera | Director of Wellness | Interviewed during investigation; acknowledged bed was broken and had Maintenance Director check it |
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation visit |
| Cara Smith | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 132
Deficiencies: 0
Dec 20, 2022
Visit Reason
An unannounced case management visit was conducted regarding an incident reported to the Community Care Licensing Division on December 2, 2022, involving a resident who eloped from the facility.
Findings
The facility reported that Resident #1, diagnosed with dementia, eloped but returned safely without injury. The facility took steps to ensure basic services were met and assigned a private caregiver until the resident moves to a more secure environment. No citations were issued.
Complaint Details
The visit was triggered by a complaint related to Resident #1 eloping from the facility. The complaint was investigated and found to be unsubstantiated as no citations were issued.
Report Facts
Census: 64
Total Capacity: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mindy Han | Administrator | Met with Licensing Program Analyst during the visit and provided information about the incident |
| Komal Charitra | Licensing Program Analyst | Conducted the unannounced case management visit |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 132
Deficiencies: 0
Oct 11, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations of neglect and lack of supervision after a client was injured leaving the facility unassisted, and failure to evaluate a resident after several AWOLs and police interventions.
Findings
The investigation found the allegation of neglect/lack of supervision unsubstantiated as the resident was able to leave the facility unassisted per doctor's orders. The allegation that facility staff failed to evaluate the resident after several AWOLs and police interventions was found to be unfounded, with no evidence supporting prior police interventions or AWOL incidents.
Complaint Details
The complaint involved allegations that a resident was injured after leaving the facility unassisted and that staff failed to evaluate the resident after several AWOLs and police interventions. The investigation concluded the neglect allegation was unsubstantiated and the failure to evaluate allegation was unfounded.
Report Facts
Facility capacity: 132
Census: 63
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Komal Charitra | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Jeffrey Dillon | Administrator | Facility administrator involved in the investigation |
| Mindy Han | Administrator | Facility administrator met during the investigation |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 63
Capacity: 132
Deficiencies: 1
Oct 11, 2022
Visit Reason
An unannounced case management visit was conducted to deliver findings related to a complaint investigation regarding an outdated physician's report for Resident #1.
Findings
The facility failed to maintain an updated physician's report for Resident #1, with the last report dated 1/19/2018, which poses a potential health and safety risk to residents in care.
Complaint Details
The visit was triggered by complaint control number 14-AS-20211221110610. The deficiency was substantiated as the facility failed to keep an updated physician's report for Resident #1.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain an updated physician's report for Resident #1. | Type B |
Report Facts
Capacity: 132
Census: 63
Deficiency POC Due Date: Oct 18, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Dillon | Administrator | Named in relation to the inspection and findings. |
| Mindy Han | Administrator | Met with Licensing Program Analyst during the visit. |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Cara Smith | Licensing Program Manager | Supervisor overseeing the inspection. |
Inspection Report
Complaint Investigation
Census: 64
Capacity: 132
Deficiencies: 1
Mar 25, 2022
Visit Reason
An unannounced case management visit was conducted in conjunction with a complaint closure related to a staff person not being associated with the facility.
Findings
It was found that a staff person (S1) was not associated with the facility but had fingerprint clearance and was still employed and providing care. This resulted in a civil penalty.
Complaint Details
Complaint received on 08/31/2021 regarding a staff person not associated with the facility. The violation was substantiated and resulted in a civil penalty.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to request a transfer of criminal record clearance for staff person S1, posing an immediate health and safety risk to clients. | Type B |
Report Facts
Civil penalty amount: 1000
Penalty rate: 100
Penalty duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Abella Tolmasoff | Licensed Vocational Nurse (LVN) | Met with Licensing Program Analyst during visit and confirmed staff association status |
Inspection Report
Complaint Investigation
Census: 4
Capacity: 132
Deficiencies: 0
Mar 25, 2022
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations of inadequate staff supervision and a questionable death at the facility.
Findings
The investigation found the allegation of inadequate supervision to be unfounded, with sufficient staff present during the incident. The allegation regarding the questionable death was unsubstantiated, with evidence showing the resident fell and staff called 911, but CPR was delayed.
Complaint Details
The complaint involved allegations that staff did not provide adequate supervision and a questionable death. The supervision allegation was found unfounded, and the death allegation was unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 132
Census: 4
Staff present: 2
Delay in CPR: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jaime Vado | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Abella Tolmasoff | LVN | Met with Licensing Program Analyst during the investigation |
| Jeffrey Dillon | Administrator | Facility administrator named in the report |
| Brenda Chan | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 132
Deficiencies: 3
Mar 3, 2022
Visit Reason
The visit was a complaint investigation conducted as a case management visit to evaluate compliance with COVID-19 protocols.
Findings
The inspection found that the COVID isolation room was not properly identified with signage, the isolation cart with PPE was not set up outside the isolation room, and handwashing reminder signs were missing at sinks in public bathrooms. The licensing program analyst reminded the facility staff to follow the COVID Mitigation Plan protocols.
Complaint Details
Complaint visit conducted by Licensing Program Analyst Jeung; deficiencies related to COVID-19 protocol signage and PPE setup were observed.
Deficiencies (3)
| Description |
|---|
| COVID isolation room is not identified as such by signage |
| Isolation cart with PPE is not set up outside of isolation room |
| Handwashing reminder signs are not posted at each sink in public bathrooms |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Galimba | LVN | Met with during the inspection and reminded to refer to COVID Mitigation Plan protocols. |
| Monica Santos | Consultant | Met with during the inspection. |
| Audrey Jeung | Licensing Program Analyst | Conducted the complaint visit and observed deficiencies. |
Inspection Report
Complaint Investigation
Census: 70
Capacity: 132
Deficiencies: 0
Mar 3, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations received on 09/16/2021 regarding physical abuse of a resident, staff not allowing visitors, and neglect of incontinence care.
Findings
The investigation determined the allegations of physical abuse and visitor restrictions to be unfounded, with no evidence supporting the claims. The allegation of neglect in assisting with incontinence was unsubstantiated due to insufficient evidence to prove or disprove the claim.
Complaint Details
Allegations included physical abuse of a resident, staff not allowing visitors, and neglect of incontinence care. The physical abuse and visitor restriction allegations were found to be unfounded, while the incontinence neglect allegation was unsubstantiated.
Report Facts
Capacity: 132
Census: 70
Inspection Report
Complaint Investigation
Census: 70
Capacity: 132
Deficiencies: 1
Mar 3, 2022
Visit Reason
The visit was a case management incident investigation related to a client admitted on 3/2/22 who was non-ambulatory and required assistance with activities of daily living. The Licensing Program Analyst (LPA) also inquired about another client who moved out on 3/1/22.
Findings
A deficiency was cited for failure to provide adequate care and supervision, as client #1 eloped from the facility without staff knowledge, posing an immediate risk to the client's health, safety, and welfare.
Complaint Details
The visit was complaint-related, investigating an incident where client #1 eloped from the facility without staff knowledge. The deficiency was substantiated as the licensee failed to ensure client supervision, posing immediate risk.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic services requirement not met: failure to provide ongoing assistance with ADLs, resulting in client #1 eloping from the facility without staff knowledge, posing immediate risk to health, safety, and welfare. | Type A |
Report Facts
Capacity: 132
Census: 70
Plan of Correction Due Date: Mar 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joy Galimba | LVN | Met with LPA during the visit |
| Monica Santos | Consultant | Met with LPA during the visit and provided client admission information |
| Jeffrey Dillon | Administrator | Facility administrator absent during the visit |
| Audrey Jeung | Licensing Program Analyst | Conducted the inspection and signed the report |
| Julio Montes | Licensing Program Manager | Supervisor named in the report |
Inspection Report
Complaint Investigation
Capacity: 132
Deficiencies: 2
Dec 15, 2021
Visit Reason
An unannounced Case Management visit was conducted regarding an incident on December 8, 2021, where Resident R1 left the facility and was still missing. The incident was not reported to Licensing as required.
Findings
The facility failed to update the pre-admission appraisal for Resident R1 after several unusual incidents and failed to report the incident of R1 leaving the facility to the licensing agency within 24 hours. These deficiencies pose potential health, safety, and personal rights risks to the resident.
Complaint Details
The visit was complaint-related due to an incident where Resident R1 left the facility unsupervised on December 8, 2021. The complaint was substantiated by findings that the facility failed to report the incident and failed to update the resident's appraisal as required.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update the pre-admission appraisal to reflect significant changes in Resident R1's condition after several incidents. | Type B |
| Failure to report the incident of Resident R1 leaving the facility without staff knowledge to the licensing agency within 24 hours. | Type B |
Report Facts
Capacity: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeffrey Dillon | Administrator | Present during the visit and discussed the report |
| Ivan Emiliano | Director of Resident Care | Met with Licensing Program Analysts during the visit |
| Komal Charitra | Licensing Program Analyst | Conducted the inspection and authored the report |
| Julio Montes | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 65
Capacity: 132
Deficiencies: 0
Aug 25, 2021
Visit Reason
An unannounced complaint investigation visit was conducted in response to allegations received on 07/23/2021 concerning resident falls, staff neglect related to soiled diapers, facility phone responsiveness, and wheelchair disrepair.
Findings
All allegations were investigated through interviews, record reviews, and observations. Each allegation was found to be unsubstantiated due to lack of evidence or contradictory information from facility staff and documentation.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident fall with injury, staff leaving a resident in soiled diapers causing bladder infection, facility phone not being answered, and a resident's wheelchair being in disrepair. None of these were substantiated after investigation.
Report Facts
Facility capacity: 132
Census: 65
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mohamed Filouane | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Jeffrey Dillon | Administrator | Interviewed during investigation and named in findings |
| Julio Montes | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 132
Deficiencies: 0
May 20, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were over-medicating a resident.
Findings
The investigation found that medication was administered accurately as prescribed, and the complaint was determined to be unfounded.
Complaint Details
The complaint alleging staff over-medicating a resident was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.
Report Facts
Capacity: 132
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mohamed Filouane | Licensing Program Analyst | Conducted the complaint investigation and follow-up visit |
| Jeffrey Dillon | Administrator | Interviewed during the investigation and recipient of findings |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 124
Deficiencies: 0
Nov 17, 2020
Visit Reason
An unannounced complaint investigation was conducted following a complaint received on 2020-10-05 regarding a resident allegedly not having a pull cord.
Findings
The investigation found that the resident did have a pull cord behind the bed and a call necklace. The facility had experienced a call system issue in early October but fixed it within the same week. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that a resident did not have a pull cord. The investigation included video calls, staff interviews, and review of images. The allegation was unsubstantiated.
Report Facts
Capacity: 124
Census: 51
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mohamed Filouane | Licensing Program Analyst | Conducted the complaint investigation |
| Jeffrey Dillon | Administrator | Facility administrator involved in investigation and interview |
| Julio Montes | Licensing Program Manager | Named in report as Licensing Program Manager |
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