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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 09/20/2021
Date Signed: 09/20/2021 05:46:36 PM

Document Has Been Signed on 09/20/2021 05:46 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:LYNNE & ROY M FRANK RESIDENCESFACILITY NUMBER:
385601084
ADMINISTRATOR:POWONDRA, MATTHEW RFACILITY TYPE:
740
ADDRESS:ONE AVALON AVENUETELEPHONE:
(415) 469-2359
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 220CENSUS: 86DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Edwina TangTIME COMPLETED:
06:00 PM
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LPA Audrey Jeung toured facility and grounds, consisting of studio, 1-bedroom and 2-bedroom units on 5 floors. Thirty rooms comprise the memory care unit on the third floor, where there are 4 exits equipped with a 30 second delayed egress: one is tested and operates as required. This unit has 2 small dining rooms and an outdoor patio. There are 2 additional memory care units that are not yet in use--on the 2nd and 4th floors. The rest of the building accommodates assisted living residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room for assisted living residents on the ground level, which accesses an outdoor courtyard. On the ground floor, there are common use rooms--lounges, theater, performance center, cafe, salon, and fitness center. The pool is not yet available to residents.
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. Liquid soap is available in common bathrooms and private bathrooms of assisted living bathrooms. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Edwina Tang is a certified RCFE administrator (x 11/21) that oversees facility operations.
The following updated licensing forms or information are requested to be submitted to CCLD BY 9/27/21:
- Board Resolution designating Ms. Tang as facility administrator
- Personnel Report (LIC500)
- Proof of liability insurance
- Written notification of facility public phone number and email address (to receive CDSS notifications)

COVID Mitigation Plan is provided to LPA today. This may have been submitted to CCLD previously.
No deficiencies of the CA Code of REgulations, Title 22 are observed. FAcility is operating in substantial compliance with Title 22 RCFE regulations.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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