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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601058
Report Date: 10/13/2026
Date Signed: 10/13/2026 02:20:36 PM

Document Has Been Signed on 10/13/2026 02:20 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:PORTOLA PLACEFACILITY NUMBER:
415601058
ADMINISTRATOR/
DIRECTOR:		ATIENZA, ARMANDFACILITY TYPE:
740
ADDRESS:445 PORTOLA DRIVETELEPHONE:
(650) 349-1755
CITY:SAN MATEOSTATE: CAZIP CODE:
94403
CAPACITY: 6CENSUS: 6DATE:
10/13/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Administrator - Armand AtienzaTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
NARRATIVE
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On 10/13/2026, Licensing Program Analyst (LPA) Vado Jaime Vado conducted an unannounced annual required inspection visit. LPA met with the licensee/administrator Armand Atienza and explained the purpose of today's visit. There are 2 caregivers in the facility, the administrator, 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 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. LPA observed the facility kitchen which is in good repair. Knives are stored and locked per observations 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. Cleaning supplies are primarily stored in the garage per observations made, which is locked. Uncovered vegetables, and expired vegetables, are observed in the main refrigerator. These are removed today during today's visit. LPA observed cleaning supplies locked beneath the kitchen sink, which is secured and not accessible to residents. In the back hallway, LPA observed unlocked gardening supplies such as pruning shears, hand rake, and a shovel that was just acquired by the facility per the administrator.

Continued on next...
April Cowan
Jaime Vado
DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: PORTOLA PLACE
FACILITY NUMBER: 415601058
VISIT DATE: 10/13/2026
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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 pre poured medications for the day in for all residents, and hospice comfort medication such as Haloperidol was not double locked in medication cabinet. 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 06/18/2025. 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 108F from a common full bathroom located in the main hallway. Walk in shower is observed to be clean and has non-skid mat for use. 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. Residents' in room half bathrooms are observed at random as clean and in good worker order. Medications and logs are observed today as current. During today's inspection LPA reviewed 4 resident files. 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 10/20/2026:

• Copy of updated administrator certificate
• Copy of facility liability insurance
• 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 page.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Jaime Vado
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/13/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 10/13/2026 02:20 PM - It Cannot Be Edited


Created By: Jaime Vado On 10/13/2026 at 12:55 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: 10/13/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/20/2026
Section Cited
CCR
87555(b)(8)

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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:
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These items were removed and discarded in the presence of LPA during today's visit.

This deficiency is cleared.
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Based on observations made of the items in the facility refrigerator in the main kitchen, it is observed that some fresh food items were not properly sealed in containers, and are exposed such as romaine lettuce, carrots, and other vegetables. This poses a potential health and safety risk to residents in care.
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Type B
10/20/2026
Section Cited
CCR87463(a)

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87463(a) Reappraisals - The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.This regulation has not been met as evidenced by:
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Facility shall develop a written plan showing how it will meet this regulation at all times. Written plan shall be submitted by the due date shown.
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Based on resident records reviewed, 1 of 5 residents have LIC625 on file. LIC625 is considered as part of the reappraisal, and all apprasails are to be trasferred to the LIC625.
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Jaime Vado
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/13/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2026


LIC809 (FAS) - (06/04)
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