Portola Gardens

Allegation investigated: Staff do not prevent residents from smoking inside the facility

On 08/25/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced complaint investigation visit. LPA met with Administrator, Gregory Bogart, LPA explained the purpose of the visit. Regarding the allegation that staff do not prevent residents from smoking inside the facility, the Department conducted an investigation and based on interviews, document review, and information obtained during the visit, there is insufficient evidence to establish that the facility did not take action to address R1's smoking inside the facility. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 25, 2026 · control 14-AS-20260501092942

Allegation investigated: Staff are not able to communicate with residents.

On 07/22/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced complaint investigation visit. LPA met with Administrator, Gregory Bogart, LPA explained the purpose of the visit. Regarding the allegation that staff are not able to communicate with residents, the Department conducted an investigation and based on interviews, observations, and information obtained during the visit, facility had staff available who were able to communicate sufficiently during emergency situations and respond to residents' immediate health and safety needs. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 22, 2026 · control 14-AS-20260522165341

Type of visit: Case Management - Other

On 7/22/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a case management. The purpose of the case management is to address the corresponding complaint investigation report number 14-AS-20260522165341. LPA met with administrator, Gregory Bogart. LPA explained the purpose of the visit. Regarding the allegation that staff are not able to communicate with residents, the Department conducted an investigation and based on interviews, observations, and information obtained during the visit, facility had staff available who were able to communicate sufficiently during emergency situations and respond to residents' immediate health and safety needs. At the time of the visit, no residents were observed to be in immediate danger due to communication barriers. Facility should ensure adequate English language proficiency among staff on duty to effectively provide routine care, understand residents' needs, and maintain the level of services required by Title 22. A technical violation was issued and discussed with the administrator. This report was reviewed with the administrator, and a copy was provided to the facility.the state’s words, verbatim · CDSS document, Jul 22, 2026

Allegation investigated: -Staff handled resident in a rough manner -Resident sustained injuries while in care -Staff did not ensure hot water was availabe at the facility for residents' use

On 04/07/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced complaint investigation visit. LPA met with Administrator, Gregory Bogart, LPA explained the purpose of the visit. Regarding the allegation that staff handled the resident in a rough manner, the Department conducted an investigation. During interview with residents and staffs, Resident R1 denied that staff handled her roughly and stated that staff were gentle during showering. Regarding the allegation that the resident sustained injuries while in care, the Department conducted an investigation. Resident R1 denied that any injuries occurred during care. No documentation was provided indicating that an injury occurred while in care, and the staff and Administrator reported no injuries requiring medical attention. cont to 9099C Unsubstantiated Regarding the allegation that staff did not ensure hot water was available for residents’ use, the Department conducted an investigation. Resident R1 reported that hot water was available, and staff denied any ongoing issues. The facility provided documentation of water heater replacement. The LPA tested water temperatures in three shower rooms and found them to be within regulatory compliance. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator.the state’s words, verbatim · CDSS document, Apr 7, 2026 · control 14-AS-20260127162859

Allegation investigated: -Staff do not follow residents care plans for 2 person assist resulting in a resident injury -Licensee does not ensure staff have the ability to communicate with residents

On 03/24/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced complaint investigation visit. LPA met with Administrator, Gregory Bogart, LPA explained the purpose of the visit. Regarding the allegation that staff do not follow residents’ care plans requiring a two-person assist resulting in a resident injury, the Department conducted an investigation. Interviews with resident R1 and staffs indicated that resident R1 received assistance from three staff members, and that R1’s fall was not related to staff assistance. A review of records, including the hospital after-visit summary, documented that R1 was diagnosed with abdominal pain of unspecified causes. Regarding the allegation that the licensee does not ensure staff have the ability to communicate with residents, the Department conducted an investigation. Interviews with staffs and residents indicated that staff are able to communicate with residents. Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove whether the allegations did or did not occur, therefore the above allegations are UNSUBSTANTIATED. Report is reviewed and a copy of this report is provided to the administrator. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 24, 2026 · control 14-AS-20260112162335

Type of visit: Case Management - Other

On 3/24/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a case management. The purpose of the case management is to address the corresponding complaint investigation report number 14-AS-20260112162335 and 14-AS-20260127162859. LPA met with administrator, Gregory Bogart. LPA explained the purpose of the visit. During complaint investigation, document were reviewed, Facility Progress notes for resident R1 and Hospital after visit summary indicate that R1 suffered a fall resulted in a hospital visit. There was no incident report on file submitted by the facility to CCL documenting the incident involving R1. Physician communication and instructions reported resident R2 was assessed by paramedics and brought to a hospital. There was no incident report on file submitted by the facility to CCL documenting the incident involving resident R2. SOC341 reported allegation of incident involved staff S1 and resident R3. There was no incident report or SOC341 on file submitted by the facility to CCL regarding the incident involving resident R3. Deficiencies of the California Code of Regulations, Title, 22 cited on the 809-D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Mar 24, 2026

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87211(a)(1) · Plan of correction due date: Mar 31, 2026

Reporting Requirements: A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of… Any incident which threatens the welfare, safety or health of any resident. This requirement is not met as evidenced by: Based on document review, facility did not submit a written report to the Department for fall occurrences of R1 and R2 and alleged physical abuse on R3, which is a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 24, 2026

Plan of correction: Facility to submit a copy of in-service training regarding reporting requirements with staff who document LIC624s to CCLD by POC due date.

Type of visit: Required - 1 Year

On 03/18/2026, Licensing Program Analyst (LPA) Yi Sam Jian arrived at the facility to conduct the unannounced required 1 year annual inspection visit. LPA met staff coordinator, Lea Salazar, LPA explained the purpose of the visit. Administrator Gregory Bogart arrived later during the visit. LPA toured facility, which consists of shared and private studio apartments on ground and 2nd floors of this 3- story community. Common areas include lobby, sun room, dining room and expansive outdoor space, which includes level patio. There are no accessible bodies of water or fire safety hazards observed. Medications are stored in locked medication room on 2nd floor and chemicals are stored in locked rooms. All outdoor and indoor passageway were free and clear of obstruction. Kitchen was inspected, sufficient supply of food observed. Infection control practices reviewed. Toxins and sharps stored appropriately and inaccessible to clients, a comfortable temperature was maintained, hot water temperature inspected to be compliant. Carbon monoxide detector and smoke detector system inspected and met the requirements. Fire extinguisher checked and fully charged. Facility has a written emergency disaster plan. First-aid kits are inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Deficiencies of the California Code of Regulations, Title 22, and technical violations are cited on following pages. Report was reviewed with LVN Melissa Grace Munoz, copy of report and Appeal Rights are providedthe state’s words, verbatim · CDSS document, Mar 18, 2026

The state marks this report as 6 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Yi Sam Jian arrived on 02/04/2026 to conducted an unannounced case management visit to follow up on approved fire clearance. LPA met with Administrator Gregory Bogart, LPA explained the purpose of the visit. The facility submitted a request to increase capacity from 104 to 132. Approved fire clearance for the change from the San Francisco Fire Department (SFFD) has been received by licensing office. LPA conducted a tour of the facility with the administrator. Physical plant is consistent with the submitted facility sketch/floor plan. There are 12 double-bed bedrooms in the north wing of second floor, 4 staff rooms on the second floor that will be convert to 4 double-bed bedrooms, 4 double-bed bedrooms in the west wing of second floor, 13 double-bed bedrooms in the south wing of the second floor, 6 single-bed bedrooms in the south wing of the second floor, 30 double-beds on the first floor remind unchanged. Upon review and approval, facility will be sent an updated license showing the change requested. LPA reviewed this report with the administrator, and a copy was provided to the administrator.the state’s words, verbatim · CDSS document, Feb 4, 2026

Type of visit: Case Management - Other

On 12/30/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit to follow up on approved fire clearance. LPA met with Administrator Gregory Bogart, LPA explained the purpose of the visit. The facility submitted a request to increase capacity from 104 to 132. Per the licensee’s communication to the CCL Regional Office, it was reported that the San Francisco Fire Department (SFFD) had approved the capacity increase. However, the administrator clarified that the SFFD inspector visited the facility on this date solely to inspect completed fire door work on the first floor and second floor of the north side of the building. The administrator further reported that the facility has not submitted a new request for a fire clearance inspection related to the capacity increase; therefore, no fire clearance approval has been issued for the requested increase. LPA conducted a tour of the facility with the administrator, who demonstrated the installation of new fire-rated doors on the first and second floors of the building’s north wing. The administrator also reported that a new sprinkler system was installed in the ceiling of the chapel and dining hall. LPA reviewed this report with the administrator, and a copy was provided to the administrator.the state’s words, verbatim · CDSS document, Dec 30, 2025

Type of visit: Case Management - Incident

On 11/04/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit regarding an incident report. LPA met with Health and Wellness Director, Navpreet Kaur, and Administrator Gregory Bogart, LPA explained the purpose of the visit. On 10/14/2025, Desk Duty LPA received a SOC 341 report regarding an incident in which staff member S1 allegedly made a gesture and struck resident R1. LPA attempted to interview resident R1 to confirm the details of the incident; however, R1 fell asleep during the interview and appeared visibly tired. The facility reported no injury to resident R1, and that although the internal investigation determined the incident to be unsubstantiated, staff member S1 is no longer employed at the facility, and additional training was provided to all staff. The LPA requested that facility submit an incident report in addition to the SOC 341. LPA reviewed this report with the administrator, and a copy was provided to the administrator.the state’s words, verbatim · CDSS document, Nov 4, 2025

Allegation investigated: - Staff are not meeting resident's medical needs. - Staff isolates resident. - Resident is not provided with adequate dining accommodations.

THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 09/05/2025. On 11/04/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver an amended copy of LIC9099. LPA met with administrator Gregory Bogart and explained the purpose of the visit. During the visit on 09/05/2025, LPA interviewed R1’s emergency contact, and collected documents. Regarding the allegation that the staff are not meeting resident's medical needs. Interviews with both the R1 and R1’s personal friend revealed conflicting and contradictory informations, indicating that the reported issues were related to an external medical center and a different facility, not the current facility. Continued onto LIC9099-C Unsubstantiated THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 09/05/2025. Regarding the allegation that the staff isolate resident, during the investigation, interviews with multiple residents provided statements that contradicted this allegation. Residents interviewed reported that they were free to socialize, participate in communal activities, and dine with others without restriction. No reported incident of resident experiencing or observing any form of intentional isolation by staff. Observations conducted during the visit did not reveal any evidence of inappropriate seclusion. Facility staff reported that meals may occasionally be served in residents’ rooms based on medical needs or personal preference, but there is no policy or practice of isolating residents. Regarding the allegation that the Resident is not provided with adequate dining accommodations, interviews conducted with multiple residents revealed statements that contradicted this allegation. Residents interviewed expressed satisfaction with the dining services, including food quality, accessibility, and the overall dining experience. LPA observed the dining area and found it to be clean, organized, and appropriately set up for resident use. The Department has investigated the above allegations. The allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Report is reviewed with administrator and a copy is provided.the state’s words, verbatim · CDSS document, Sep 5, 2025 · control 14-AS-20250430161305

Allegation investigated: -Resident was not accorded dignity in their relationship with staff and other residents

On 07/18/2025 Licensing Program Analysts (LPAs) Yi Sam Jian met with staffing coordinator, Lea Salazar, to conduct a complaint investigation. Purpose of visit explained. Administrator, Gregory Bogart arrived later during the visit. LPA gathered information relevant to allegations. LPA conducted staff interviews. Regarding the allegation that Resident was not accorded dignity in their relationship with staff and other residents, multiple staff confirmed the comment was made and found it inappropriate. Staff's comment and lack of understanding regarding resident dignity and privacy policies constitute a violation of residents’ personal rights. Based on interviews and file reviews during the course of the investigation it was determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Report is reviewed with administrator and a copy is provided. Substantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 14-AS-20250502104955

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Jul 28, 2025

Personal Rights requirement: Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff, residentsthe state’s words, verbatim · CDSS document, Jul 18, 2025

Plan of correction: The Administrator shall develop and implement a plan to ensure all staff fully understand and uphold residents’ right to dignity in interactions with staff and resident. A copy must be submitted to CCL by the POC due date. Failure to comply may result in a civil penalty.

Allegation investigated: Facility did no allow residents to have visits

On 07/18/2025 Licensing Program Analysts (LPAs) Yi Sam Jian met with staffing coordinator, Lea Salazar, to conduct a complaint investigation. Purpose of visit explained. Administrator, Gregory Bogart arrived later during the visit. LPA gathered information relevant to allegations. LPA conducted resident interview. Regarding the allegation that the facility did not allow residents to have visits, no evidence was found to support this claim beyond the reporting party’s statement. All other resident interviews indicated that visitation was not denied. The Department has investigated the above allegations. The allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Report is reviewed with administrator and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 14-AS-20250603154003

Allegation investigated: Staff did not ensure a comfortable environment was provided for residents.

On 05/28/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced 10-day complaint visit. LPA met with administrator, Gregory Bogart, and Health and Wellness Director, Navpreet Kaur, LPA explained the purpose of the visit. During the visit, LPA interviewed staffs, and collected documents. Regarding staff did not ensure a comfortable environment was provided for residents. The reported noise was temporary and related to essential maintenance work during the installation of a sprinkler system. Earplugs were provided to residents to reduce any discomfort, and measures to mitigate the impact were reviewed. No verified harm was reported, no evidence of residents requiring medical attention, and no additional formal complaints were found. The Department has investigated the above allegations. The allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 14-AS-20250523093321

Allegation investigated: Staff engaged in inappropriate sexual behavior in resident's room. Facility staff are not meeting resident's hygiene needs.

On 04/24/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver an amended copy of LIC9099. LPA met with administrator Greg Bogart and explained the purpose of the visit. Regarding the allegation that Staff engaged in inappropriate behavior in resident's room, the department was provided with video evidence showing a female staff lowering her pant in the presence of a male staff while inside the resident’s room. Regarding the allegation that facility staff was not meeting the resident’s hygiene needs: The Service Plan dated 12/06/2024 indicates that the resident was to receive full assistance with bathing on a daily basis. No shower assistance was logged on 12/06/2024-12/07/2024. Based on interviews and document review during the course of the investigation, the department determined that the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Substantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 14-AS-20241205100317

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(1) · Plan of correction due date: Apr 25, 2025

Personal Rights requirement: Residents in all residential care facilities for the elderly shall…be accorded dignity in their personal relationships with staff This requirement is not met as evidenced by: Based on video evidence showing two staffs engaging in inappropriate conduct inside the resident’s room. This serious violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: The Licensee/Administrator shall develop and implement a plan to ensure that staff do not engage in inappropriate conduct in resident’s room. A copy of the plan must be submitted to CCL by 04/25/2025. Failure to correct this deficiency by due date may result in a civil penalty

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(a)(4) · Plan of correction due date: Apr 29, 2025

Personal rights requirement: To care, supervision, and services that meet their individual needs This requirement was not met, as evidenced by file reviews and interviews indicating that the documentation in the shower log was inconsistent with the bathing schedule outlined in the Service Plan. This violation poses a potential health, safety or personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Administrator agreed to submit proof of correction with a written plan outlining how this violation will be avoided in the future to licensing office by 04/29/2025. Failure to correct this deficiency by due date may result in a civil penalty.

Allegation investigated: -Resident sustained injury due to lack of supervision. -Facility failed to conduct reappraisal of resident after significant change in resident's physical, mental, cognitive, behavioral, or functional condition.

On 04/24/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver conclusionary finding for this complaint received by the Department on 01/24/2025. LPA was greeted by administrator Greg Bogart and explained the purpose of the visit. Regarding the allegation that Resident sustained injury due to lack of supervision, client’s care, supervision and services were not adjusted in December 2024 to prevent harm to other client, despite documented incidents of client exhibiting harm toward staffs in December 2024. Regarding the allegation that facility failed to conduct reappraisal of resident after significant change in resident's physical, mental, cognitive, behavioral, or functional condition, client was not reappraised after documented incidents of exhibiting harm to staffs. Based on interviews and file reviews during the course of the investigation it was determined that the preponderance of evidence standard has been met, therefore the allegations above are found to be SUBSTANTIATED. The deficiency is cited in accordance with California Code of Regulations, Title 22 Division 6, Chapter 8 and is noted on the attached LIC 9099-D. Substantiatedthe state’s words, verbatim · CDSS document, Apr 24, 2025 · control 14-AS-20250124101153

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468(a)(4) · Plan of correction due date: Apr 25, 2025

Personal rights requirement: To care, supervision, and services that meet their individual needs This requirement was not met, as evidenced by file reviews and interviews revealed that the client’s care, supervision and services were not adjusted to prevent harm to other client, despite documented incidents of client exhibiting harm toward staffs. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Administrator agreed to submit proof of correction with a written plan outlining how this violation will be avoided in the future to licensing office by 04/25/2025. Failure to correct this deficiency by due date may result in a civil penalty

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87463(b)(1)(C) · Plan of correction due date: Apr 25, 2025

Reappraisals requirement: The reappraisal shall document significant changes in…Behavioral expression…that may result in harm to self or others. This requirement was not met, as evidenced by file reviews and interviews, which revealed that the client was not reappraised after documented incidents of exhibiting harm to staffs. This violation poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Apr 24, 2025

Plan of correction: Administrator agreed to submit proof of correction with a written plan outlining how this violation will be avoided in the future to licensing office by 04/25/2025. Failure to correct this deficiency by due date may result in a civil penalty

Type of visit: Case Management - Incident

On 03/28/2025, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit regarding an incident report. LPA met with Administrator Gregory Bogart, LPA explained the purpose of the visit. On 02/28/2025, Desk Duty LPA received a report regarding a care partner allegedly made sexual comment to resident R1. LPA interviewed R1 to confirm incident. LPA interviewed administrator and reviewed files. The administrator stated that the care partner, who had only been employed at the facility for two weeks and allegedly made the sexual comment, is no longer employed at the facility. Facility to provide copies of Relias staff training on topics such as resident rights, personal boundaries, professionalism, elder abuse, and/or caregiver conduct by 04/08/2025. LPA has reviewed this report with administrator, and a copy of the report was provided to administrator.the state’s words, verbatim · CDSS document, Mar 28, 2025

Type of visit: Required - 1 Year

On 02/25/2025, Licensing Program Analyst (LPA) Yi Sam Jian, Grace Donato and Licensing Program Manager (LPM) April Cowan arrived at the facility to conduct the unannounced required 1 year annual inspection visit. LPAs and LPM met with Health and Wellness Director, Navpreet Kaur, LPA explained the purpose of the visit. Administrator Gregory Bogart arrived later during the visit. LPAs and LPM toured facility, which consists of shared and private studio apartments--all of which include sink and vanity--on ground and 2nd floors of this 3- story community. Each room has an emergency pull alarm, which transmits audio and visual signal to monitors in medication room and front desk. Thirty apartments are inspected. Common areas include lobby, sun room, dining room and expansive outdoor space, which includes level patio. There is one elevator and 5 interior stairwells, plus 2 exterior fire exit stairs. There are no accessible bodies of water or fire safety hazards observed. Medications are stored in locked medication room on 2nd floor and chemicals are stored in locked rooms. A comfortable temperature is maintained and passageways are clear. Hot water temperature checked in bed rooms and common bathrooms within range of 105 - 118 degrees F. There are at least 16 full bathrooms that are equipped with grab bars and nonskid flooring material. Food supply and first-aid kit are inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Staff records, including training were reviewed. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages, per record review made today. Report was reviewed with Administrators, copy of report and Appeal Rights are providedthe state’s words, verbatim · CDSS document, Feb 25, 2025

Type of visit: Case Management - Other

On 1/7/2025, Licensing Program Analyst (LPA) Tobola arrived unannounced for the purpose of conducting a case management to follow up on multiple changes within the facility, including an increase in capacity request and a change of license. LPA was greeted by Executive Director, Greg Bogart. LPA and staff toured the facility and inspected resident bedrooms pertaining to the capacity increase request. There are currently 91 residents residing in the facility which is within the current capacity. LPA confirmed count on resident census documentation. The facility's request is to update several bedrooms on the second floor to house ambulatory residents and allow additional double occupancy bedrooms. LPA inspected the non-ambulatory and bedridden portions of the facility and found no concerns or over capacity. San Francisco Fire Department is scheduled to conduct a fire inspection on 1/8/2025. Four rooms currently used as offices and storage space will be converted back into resident use if fire clearance is approved. Additional licensing inspection may follow to confirm resident room accommodation requirements are met. Executive Director will contact LPA upon completion and the fire inspection clearance report to be provided. LPA and Executive Director discussed the plans for change of ownership and sale of the facility. Executive Director stated that the facility is in the process but has not finalized the sale. LPA was provided a copy of the notification letter sent out to residents and families dated 11/29/2024. The letter indicates that the change of ownership will occur on or around 12/31/2024. LPA requested for documentation of the company having notified Community Care Licensing of the intent to change ownership/sell the facility. LPA to conduct follow up visit once documentation is received. No deficiencies cited during visit.the state’s words, verbatim · CDSS document, Jan 7, 2025

Type of visit: Case Management - Annual Continuation

To complete annual inspection of 4/16/24, LPA Jeung reviewed client and staff records. Deficiencies of the California Code of Regulations, Title 22, are cited on following pages, per observations made on 4/16/24 and today.the state’s words, verbatim · CDSS document, Jul 15, 2024

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.311 · Plan of correction due date: Jul 29, 2024

Every RCFE shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The Dept. shall account for the presence of these detectors during inspections. This requirement was not met, as carbon monoxide detectors were not present on 4/16/24, per administrator. This poses a potential health and safety risk for clients in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Plan/proof of correction for installation of carbon monoxide detectors will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR87307(c) · Plan of correction due date: Jul 29, 2024

PERSONAL ACCOMMODATIONS & SERVICES Individual privacy shall be provided in all toilet, bath and shower areas. This requirement was not met, as commodes were observed on 4/16/24 in shared rooms 103, 107, 116. This poses a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: Plan/proof of correction for removal of commodes in shared rooms will be sent to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87608(a)(3) · Plan of correction due date: Jul 29, 2024

POSTURAL SUPPORTS A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. The licensing agency shall be authorized to require other additional documentation if needed to verify the order. This requirement is not met, as MD orders are not maintained for half bed rails for 2 clients, which poses a potential health, safety or personal rights risk to clients. Clients #2 & #8 are missing MD orders for half bed rails. On 4/16/24, half bed rails observed for 20 beds, which require MD orders on file.the state’s words, verbatim · CDSS document, Jul 15, 2024

Plan of correction: MD orders for half bed rails for clients #2 & #8 will be sent to CCLD. MD orders should be maintained for all clients who use half bed rails. Plan/proof of correction to be sent to CCLD BY DUE DATE

Type of visit: Required - 1 Year

LPA Audrey Jeung toured facility, which consists of shared and private studio apartments--all of which include sink and vanity--on ground and 2nd floors of this 3- story community. Each room has an emergency pull alarm, which transmits audio and visual signal to monitors in medication room and front desk. Thirty apartments are inspected. Common areas include lobby, sun room, dining room and expansive outdoor space, which includes level patio. There is one elevator and 5 interior stairwells, plus 2 exterior fire exit stairs. There are no accessible bodies of water or fire safety hazards observed. Medications are stored in locked medication room on 2nd floor and chemicals are stored in locked rooms. A comfortable temperature is maintained and passageways are clear. Hot water temperature checked in 3 rooms and common bathroom within range of 105 - 120 degrees F. There are at least 16 full bathrooms that are equipped with grab bars and nonskid flooring material. PPE supplies are maintained. Food supply and first-aid kit are inspected. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Food service staff have current safe food handling certifications, including food and beverage director. Quarterly reviews are completed by a registered dietician and reports are maintained; copies of last 2 reports are given to LPA. Gregory Bogart is a certified RCFE administrator (x 5/24 that oversee facility operations. Some client medications records are reviewed. Staff records, including training, will be reviewed at a later date. The following information is requested to be submitted to CCL by 4/23/24 - Proof of current liability insurance (including coverage limits) - Proof of control of property (signed lease agreement) - LIC 309 Administrative Organization Deficiency of the California Code of Regulations, Title 22 is cited today. Also see Technical Advisory Notes--6 pages. Annual inspection to be completed at a later date.the state’s words, verbatim · CDSS document, Apr 16, 2024

Allegation investigated: Staff are sleeping at the facility.

On January 18, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unnannounced complaint visit to deliver findings for the above allegation. LPA met with Administrator, Greg Bogart and explained the purpose of the visit. Regarding the allegation staff are sleeping at the facility, according to the reporting party, two staff members on NOC shift have been sleeping in chairs at the facility during their shifts. During the visit, LPA interviewed administrator, assistant administrator, staff and residents. The administrator and the assistant administrator indicated that they have not heard or observed staff sleeping during NOC shift, however they indicated if staff choose to sleep during their (unpaid) 30-minute lunch then it's their decision. Based on 3 staff and 5 residents interviewed, they have not observed or heard of NOC shift staff sleeping during their shift. Although the above allegation may have happened or are valid, there is no evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed with Greg Bogart and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jan 18, 2024 · control 14-AS-20231227095941

Type of visit: Case Management - Deficiencies

On January 18, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to complaint control #: 14-AS-20231227095941. LPA met with Administrator, Gregory Bogart and explained the purpose of the visit. During the investigation regarding the above referenced complaint, LPA interviewed 5 residents and discovered 4/5 residents indicated that when they press their call button at night, staff do not respond in a timely manner. In addition, staff interviewed also indicated that he/she has heard complaints in the morning from residents that when they attempted to press their call pendant/button at night, staff either don't respond or respond late. LPA attempted to obtain call button/ call pendant records from the facility for review, however facility was unable to provide any documentation to show staff respond in a timely manner. Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report is reviewed with Administrator and a copy is provided with appeal rights.the state’s words, verbatim · CDSS document, Jan 18, 2024

From the deficiency page — Deficiency type: Type A · Section cited: HSC 1569.312(a) · Plan of correction due date: Jan 19, 2024

§1569.312 Basic services requirements..Every facility required to be licensed under this chapter shall provide at least the following basic services:..(a) Care and supervision as defined in Section 1569.2. Violation of this regulation is not met as evidenced by: Based on resident interviewed, 4/5 residents interviewed indicated that when they tried to press their call pendants/buttons, staff will either not respond or not respond in a timely manner which poses an immediate health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Jan 18, 2024

Plan of correction: Licensee/Administrator to submit a written plan to ensure residents call buttons/ call pendants are being responded in a timely manner.

Type of visit: Case Management - Incident

In response to Suspected Abuse Reports (SOC341) submitted to CCLD on 12/1/23 and 12/6/23, LPA Jeung met with administrator to discuss incidents and obtain updates. LPA reviewed clients' files and interviewed clients and staff. Incident reported on 12/1/23 pertains to client #1. Incident reported on 12/6/23 pertains to clients #2 and #3. Administrator is instructed to submit Unusual Incident Reports (LIC624) to CCLD whenever SOC341s are submitted. Administrator to submit completed Incident Reports to CCLD BY 12/12/23 with detailed summary of facility investigations, including names of all persons involved and contacted. Administrator reported to CCLD on Friday 12/8/23 that facility is experiencing a gastrointestinal outbreak. LPA is informed today that report was made to SF Dept. of Public Health, and recommendations were provided to administrator; copy of SFDPH recommendations obtained by LPA, as well as line list of those afflicted. Administrator is reminded to ensure that all resident appraisals and care plans are signed and acknowledged by resident or their authorized representatives. At this time, no deficiencies observed.the state’s words, verbatim · CDSS document, Dec 11, 2023

Allegation investigated: - Staff did not ensure a resident consumed an appropriate amount of fluids while in care - Staff did not ensure the residents were properly fed while in care - Staff did not meet the residents hygiene needs - Staff did not address a resident's change in medical condition - Staff did not follow infection control procedures

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to investigate the allegations received and deliver findings on the allegations. LPA met with administrator assistant Lea Salazar and explained the purpose of today's visit. During the course of the investigation interviews were conducted, pertinent resident documents are reviewed, and facility observations are made. It is discovered that there is contradicting information in regards to the allegations received versus what the facility was able to provide via interviews, observations made, and documentation. LPA is unable to prove whether the allegations took place or not due to the conflicting information. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Report is reviewed with Lea Salazar. Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 29, 2023 · control 14-AS-20230327163312

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.