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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 09/30/2022
Date Signed: 09/30/2022 05:49:25 PM

Document Has Been Signed on 09/30/2022 05:49 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
SF COASTAL AC/SC, 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: 116DATE:
09/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 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. Currently, the 4th floor memory care unit is vacant. There are residents in the third floor memory care unit--where there are 30 units--and part of the 2nd floor memory care unit. All are equipped with 30 second delayed egresses: one is tested and operates as required. In each of the memory care units, there is at least one dedicated dining room and outdoor space. 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, including indoor pool. Kitchen and food supplies are inspected.
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. Handwashing reminder signs are posted appropriately. Staff and residents are checked daily for COVID symptoms and temperature checked and documented. 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 11/23) that oversees facility operations.
The following updated licensing forms or information are requested to be submitted to CCLD BY 10/10/22:
- Administrative Organization (LIC309)
- Personnel Report (LIC500)
- Proof of liability insurance

Infection Control 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. See Technical Advisory Note for additional information.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2022
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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