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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 08/09/2024
Date Signed: 08/09/2024 04:48:03 PM

Document Has Been Signed on 08/09/2024 04:48 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:LYNNE & ROY M FRANK RESIDENCESFACILITY NUMBER:
385601084
ADMINISTRATOR/
DIRECTOR:		TANG, EDWINAFACILITY TYPE:
740
ADDRESS:ONE AVALON AVENUETELEPHONE:
(415) 562-2855
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 220CENSUS: 176DATE:
08/09/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
04:28 PM
MET WITH:Sandra Peret, Director of Health and Wellness, Michelle Delos Santos, Business Office Manager, and Rob Saraison, Assistant Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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On August 9, 2024, Licensing Program Analysts(LPAs) John Calandra and Dominic Tobola arrived at the facility at 4:28 PM to conduct an unnanounced Case Management regarding an SOC 341 and Incident Report submitted to the Department.

LPAs Calandra and Tobola requested the following documents:

-LIC 602
-Care Notes/Needs and Services Plan
-Notes from staff

An exit interview was conducted. This report was reviewed with Michelle Delos Santos, Business Office Manager, Sandra Peret, Director of Health and Wellness, and Rob Saraison, Assistant Executive Director . No Appeal rights were provided. A copy of the report was left at the facility.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
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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