Portola Place

Type of visit: Required - 1 Year

On 09/15/2025, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with the licensee Armand Atienza and explained the purpose of today's visit. There are 2 caregivers in the facility and 4 residents present. This is a two level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There are 2 hospice residents as of today's inspection visit. The second level of the facility is occupied by private renters. The access door to the second floor is secured so those renters cannot enter the facility. There is a separate entrance for that second floor unit located near the garage of the facility. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is in good repair. Knives are stored and locked per observation made. Perishable and non-perishable food supply in place. There is an additional refrigerator/ freezer in the garage area which carries additional food supplies for resident use. Refrigerator was observed to not meet regulatory standard in terms of cleanliness. Storage shelves and drawers were observed to be sticky and dirty, sticky, needing to be cleaned. Expired food items were observed such as sauces and milk were observed. Also it was observed the facility used of other food containers to store foods that were not intended to be in those containers that were originally for miso dressing and two containers of potato salads. Uncovered vegetables and fruits were also observed. Also in the garage is the laundry area and where the cleaning supplies are primarily stored. LPA also observed cleaning supplies locked beneath the kitchen sink. Continued on next... Page 2 First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet adjacent to the refrigerator. LPA observed at least one fire extinguisher in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Inspection tag for the extinguisher indicates it was checked on 07/18/2025. Facility is not equipped with fire sprinklers. LPA also observed fire pull stations in the rear and front of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature is measured at 121F and increasing during today's inspection. The temperature was adjusted during today's visit and is remeasured at 105F. Also observed in the bathroom is a common hand towel for resident use to use for drying of hands. LPA provided advisory notice that such should not be in place for resident use in order to prevent the spread of illness and other reasons. Linen supplies are observed as in place in a hallway closet. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. Shower floor is equipped with non-skid mat for resident use. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files. R1 physician's report is not current to within one year and has a dementia diagnosis and there was no other evidence on file reflecting an annual medical visit being conducted but was informed that R1 did have a medical visit and will submit evidence of the visit. Staff files are reviewed and are current. Administrator certificate is observed to be current expiring 06/16/2026. The following updated forms are requested to be submitted to CCLD by 09/22/2025: • Copy of updated administrator certificate • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule Report is reviewed with Armand and a copy of the report is provided. Citations are issued on this day on the attached LIC809D pages.the state’s words, verbatim · CDSS document, Sep 15, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2) · Plan of correction due date: Sep 16, 2025

87303(e)(2) Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by: Based on facility observations made during water temperature testing, LPA found that the water temperature in the common bathroom for the facility, the water temerature was tested at 121F and increasing. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Water temperature was lowered during today's visit and was remeasured at 105F. This citation is cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87555(23) · Plan of correction due date: Sep 16, 2025

87555(23) General Food Service Requirements - All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This regulation has not been met as evidenced by: Based on observations made of the facility refrigerators, LPA observed uncovered fresh foods such as cantalope, celery, onions, and other fresh vegetables were not covered appropriately. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times. Plan shall be submitted to the Department for review.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(i) · Plan of correction due date: Sep 16, 2025

87465(i) Incidental Medical and Dental Care - Prescription medications which are not taken with the resident upon termination of services, not returned to the issuing pharmacy, nor retained in the facility as ordered by the resident’s physician and documented in the resident’s record nor disposed of according to the hospice’s established procedures or which are otherwise to be disposed of shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. This regulation has not been met as evidenced by: Based on facility ovservations made, LPA Vado found medications from a prefious resident was not destroyed properly and was being stored in the facility's refrigerator in the main kitchen. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: This citation was cleared during LPA's inspection visit. Medications were removed, bagged and removed from the facility for destruction. This citation is cleared

From the deficiency page — Deficiency type: Type B · Section cited: CCR87463(h) · Plan of correction due date: Sep 16, 2025

87463(h) - Reappraisals -The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. This regulation has not been met as evidenced by: Based on resident files reviewed, R1's last doctor visit notated on the physician's report is 06/03/2024, which does not meet the annual routine medial visit as outlined in this regulation. This poses an immediate heatlh and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: During today's visit, LPA was informed that R1 did have a visit and will provide evidence of the visit.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87555(b)(8) · Plan of correction due date: Sep 16, 2025

87555(b)(8) General Food Service Requirements - All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This regulation has not been met as evidenced by: Based on observations made of the items in the facility refrigerator in the main kitchen, LPA found several expired items such as milk, barbecue sauce, and other items with past best use by dates. Additionally, LPA observed vegetable with mold and the reusing of containters that were for miso dressing and potato salad to store other food items hat were not originally in those containers. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times ensuring that food items will be inspected and disposed of appropriately and stored properly in appropriate containers.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87303(a) · Plan of correction due date: Sep 17, 2025

87303(a) Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This regulation has not been met as evidenced by: Based on obseravtions made of the refrigerator in the main kitchen, LPA found that the shelves, storage drawers, and storage areas of the refrigerator as dirty, sticky, and needed to be cleaned. This poses as a potential health and safety risk for residents in care.the state’s words, verbatim · CDSS document, Sep 15, 2025

Plan of correction: Facility shall develop a written plan addressing how the facility will meet this regulation going forward at all times ensuring that the refrigerator will be maintained in a clean and healthful manner at all times.

Type of visit: Required - 1 Year

On 09/23/2024, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with caregivers Tracy Byrne and Jeremiah Ricarto. LPA spoke to the licensee Armand Atienza via telephone during today's inspection. LPA explained the purpose of today's visit to the caregivers present. There are 2 caregivers in the facility and 6 residents present. This is a two level facility licensed for residents age range of 60 years and over all of which may be non-ambulatory. License is approved for 3 hospice residents. There are no hospice residents as of today's inspection visit. The second level of the facility is occupied by private renters. There is no access from the second floor into the facility. There is a separate entrance for that second floor unit located near the garage of the facility. The physical plant was toured inside and outside of the facility to ensure the safety of the residents. The floors of the facility are observed to be sticky to foot wear making an audible sticking sound through out. LPA observed spots and areas around the bathroom and resident rooms where the flooring appear to be dirty in some areas with visible marks and debris. There are no video cameras on site per the caregivers. LPA observed the facility kitchen which is in good repair. Knives are stored and locked per observation made. Perishable and non-perishable food supply in place. There is an additional refrigerator/ freezer in the garage area which carries additional food supplies for resident use. Also in the garage is the laundry area and where the cleaning supplies are primarily stored. LPA also observed cleaning supplies locked beneath the kitchen sink. First aid kit is observed as complete with required items stored in the kitchen of the facility. Medications are observed to be locked in the kitchen in a kitchen cabinet adjacent to the refrigerator. LPA observed at least one fire extinguisher in place which are currently within operating range, smoke detector, carbon monoxide detectors are observed in place through out the facility, and central heating. Continued on next... Page 2 Facility is not equipped with fire sprinklers. LPA also observed fire pull stations in the rear and front of the facility. Emergency exit routes are observed inside and outside to be free and clear of obstructions. Water temperature is measured at 123F and increasing during today's inspection. This poses an immediate health and safety risk to resident in care. Also observed in the bathroom is a common hand towel for resident use to use for drying of hands. LPA provided advisory notice that such should not be in place for resident use in order to prevent the spread of illness and other reasons. Linen supplies are observed as in place in a hallway closet. LPA observed all resident rooms as clean, free of odors, and contained all the required furniture per regulatory recommendations. Resident bathrooms are observed as clean and in good worker order. LPA did observe in a resident's half bath in their room a shelf above the toilet that is broken off the wall and resting on top of the toilet. Shower floor is equipped with non-skid mat for resident use. Facility does not handle resident monies. Medications and logs are observed today as current. During today's inspection LPA reviewed 6 resident files. R1 and R4 physician's report is not current to within one year and has a dementia diagnosis. This poses an immediate health and safety risk to the resident in care. Staff files are reviewed and are current. Administrator certificate is observed as expired as of 06/15/2024. LPA is requesting an updated copy to be sent to the Department for review. The following updated forms are requested to be submitted to CCLD by 09/30/2024: • Copy of all updated administrator certificates • Copy of facility's liability insurance • LIC308 Designation of responsible staff person • LIC610E Emergency Disaster Plan • LIC500 Staff Schedule • Copy of control of property or copy of lease Citations are issued on this day on the attached LIC809D pages. Technical violations and Technical Assistance also provided on this day on the attached LIC9102 forms. Report is reviewed with Jeremiah and Tracy and a copy of report is provided.the state’s words, verbatim · CDSS document, Sep 23, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(e)(2 · Plan of correction due date: Sep 24, 2024

87303(e)(2) Maintenance and Operation - Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). This regulation has not been met as evidenced by: Based on facility observations made during water temperature testing, LPA found that the water temperature in the common bathroom for the facility, the water temerature was tested at 123F and increasing. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 23, 2024

Plan of correction: Licensee shall develop a plan to lower the water temperature thorough out the facility, monitor, and log water temperature to ensure that the temperature is within 105F and 120F at all times.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(c)(5) · Plan of correction due date: Sep 24, 2024

87705(c)(5) Care of Persons with Dementia - Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. This regulation has not been met as evidenced by: Based on records reviewed, LPA observed that the physician's report for R1 is not current. Residents with dementia require a new physicians report annually. This poses an immediate health and safety risk to resident in care.the state’s words, verbatim · CDSS document, Sep 23, 2024

Plan of correction: Licensee shall develop a plan to maintain all residents with dementia physician's reports to be kept up to date annually. Report and evidence of R1's updated physician's report to be sent to the department.