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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 07/01/2022
Date Signed: 07/01/2022 11:43:39 AM

Document Has Been Signed on 07/01/2022 11:43 AM - 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:TANG, EDWINAFACILITY TYPE:
740
ADDRESS:ONE AVALON AVENUETELEPHONE:
(415) 562-2855
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 220CENSUS: 115DATE:
07/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rob SarisonTIME COMPLETED:
12:00 PM
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LPAs Jeung and Varilla met with assistant executive director and director of health and wellness to obtain details of incident of 6/11/22 that was reported to CCLD. LPAs reviewed file for client #1 and private companion, who was removed from facility on 6/11/22.
LPAs were advised that SF Ombudsman met with facility staff, private companion, and daughter of client to discuss incident. As a result--and based on wishes of DPOA/daughter--private companion is allowed to resume companionship to client as of 6/17/22. Private companion was provided with training by hospice agency on feeding strategies on 6/23/22.
Facility documents for private attendants--acknowledgement, indemnification, guidelines--were signed by private companion; copies are obtained. Requirements for Private Duty Attendants and Home Health Agency Personnel and Rules of Conduct of Attendants are also reviewed, but it cannot be confirmed that these documents were given to or acknowledged by private companion of client #1.

LPAs recommended that Personal Rights forms LIC613C/LIC613C2 be added to forms that private attendants be required to acknowledge when providing services to facility.

No deficiency cited.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/01/2022
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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