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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601058
Report Date: 10/14/2021
Date Signed: 10/14/2021 01:13:21 PM

Document Has Been Signed on 10/14/2021 01:13 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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PORTOLA PLACEFACILITY NUMBER:
415601058
ADMINISTRATOR:ATIENZA, ARMANDFACILITY TYPE:
740
ADDRESS:445 PORTOLA DRIVETELEPHONE:
(650) 349-1755
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
10/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Armand AtienzaTIME COMPLETED:
01:30 PM
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LPA Audrey Jeung toured facility and grounds of this 2-level home, consisting of 6 client bedrooms and a staff bedroom--each with a private half bathroom--on the main level, and a common bathroom, kitchen, living, and dining rooms. The upper level has 2 bedrooms, and is accessed from door within facility near rear door that exits to Alameda De Las Pulgas; it is occupied by tenant, and off limits to residents. There is a 2 car garage, where washer and dryer are located. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Toilet and bathing facilities are equipped with grab bars and nonskid flooring material. First-aid kit is inspected and complete. A Disaster and Mass Casualty Plan is posted. There are 6 residents present, and 2 staff. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Armand Atienza is a certified RCFE administrator (x 6/22) that oversees facility operations.

The following updated forms/information are requested to be submitted to CCLD BY 10/28/21:

• LIC 308 Designation of Administrative Responsibility
• Current lease agreement for tenant
• Current liability insurance
• In-service training requirements for staff
• RCFE Medication training requirements for staff

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. See Technical Advisory Notes for additional information.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2021
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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Document Has Been Signed on 10/14/2021 01:13 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/14/2021 at 12:23 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: 10/14/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.2
ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and confirmation by administrator, the licensee did not comply with the section cited above, as symptom and temperature checks for staff and residents are not being done and recorded on daily basis, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/28/2021
Plan of Correction
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Temperature and COVID symptom checks of residents and staff shall be done DAILY and recorded in logs. Proof of correction to be sent to CCLD BY DUE DATE, and include copies of resident and staff logs where temperature and COVID symptoms will be logged.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Julio Montes
LICENSING EVALUATOR NAME:Audrey Jeung
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2021


LIC809 (FAS) - (06/04)
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