Inspection Reports for Portola Gardens

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.

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.

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.

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.

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.

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.

An unannounced complaint investigation visit was conducted following a complaint received on 2025-05-23 regarding staff not ensuring a comfortable environment for residents.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced case management visit was conducted regarding an incident report of a care partner allegedly making a sexual comment to a resident.

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 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.

The inspection was an unannounced required 1 year annual inspection visit conducted to evaluate compliance with regulations.

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.

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.

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.

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.

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.

The visit was a required, unannounced one-year inspection of the Portola Gardens facility to evaluate compliance with regulations.

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.

An unannounced complaint investigation visit was conducted in response to an allegation that staff were sleeping during their shifts at the facility.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The complaint investigation was unsubstantiated due to lack of preponderance of evidence to prove the alleged violations occurred.

An unannounced annual visit was conducted to evaluate the facility's compliance with licensing requirements.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

An unannounced case management visit was conducted to deliver findings related to a complaint investigation regarding an outdated physician's report for Resident #1.

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.

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.

An unannounced case management visit was conducted in conjunction with a complaint closure related to a staff person not being associated with the facility.

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 received on 08/31/2021 regarding a staff person not associated with the facility. The violation was substantiated and resulted in a civil penalty.

The visit was an unannounced complaint investigation triggered by allegations of inadequate staff supervision and a questionable death at the facility.

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.

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.

The visit was a complaint investigation conducted as a case management visit to evaluate compliance with COVID-19 protocols.

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 visit conducted by Licensing Program Analyst Jeung; deficiencies related to COVID-19 protocol signage and PPE setup were observed.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff were over-medicating a resident.

The investigation found that medication was administered accurately as prescribed, and the complaint was determined to be unfounded.

The complaint alleging staff over-medicating a resident was investigated and found to be unfounded, meaning the allegation was false or without reasonable basis.

An unannounced complaint investigation was conducted following a complaint received on 2020-10-05 regarding a resident allegedly not having a pull cord.

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.

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.