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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601084
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:52:45 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220218123922
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: 106DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator, Robert SarisonTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff handled resident in a rough manner
Resident sustained injuries while in care
Facility has insufficient staffing to meet residents' needs
INVESTIGATION FINDINGS:
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On 4/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220218123922. LPA Han met with assistant administrator, Robert Sarison and the administrator, Edwina Tang joined shortly thereafter. LPA explained the purpose of the visit.

Regarding allegation of- staff handled resident in a rough manner and resident sustained injuries while in care, during the initial reporting, the reporting party stated that a male staff grabbed resident #1 (R1)'s arm that caused R1 to sustain injuries.

According to the administrator, when the facility learned about the above incident, the facility immediately removed the male staff from work, reported the incident to CCL, Ombudsman and conducted investigation. After the investigation, the male staff did not return to work and the facility provided Elder Abuse in-services to facility staff.

Based on record review, and interviews during the course of investigation, this allegation is substantiated.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 14-AS-20220218123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RESIDENCES
FACILITY NUMBER: 385601084
VISIT DATE: 04/21/2022
NARRATIVE
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Regarding to allegation of facility has insufficient staffing to meet residents' needs- during the initial 10-day complaint inspection on 2/28/22 at 11:15am, LPA and the assistant administrator entered the TV / Dinning room in Memory Care Unit 3B, LPA observed resident #2 (R2) and resident #3 (R3) were watching TV by themselves. Then, LPA observed a staff was going in and out of the kitchen that is located in the dinning room and the dinning is in the same room as the TV room but separated by a wall. LPA observed the staff who was going in and out of the kitchen did not have visual supervision of both residents as the wall was in between the 2 rooms. A few minutes later the same staff completed his/her tasks in the kitchen and left the dinning/ TV room while both residents continued to watch TV in the TV room.

Based on observation and interview during the course of the investigation, this allegation is substantiated.

Based on observation and interview during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator, and Appeal Rights provided.

A copy of this report is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 6 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Murial Han
COMPLAINT CONTROL NUMBER: 14-AS-20220218123922

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: 106DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Assistant Administrator and AdministratorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Due to lack of supervision resident sustained several falls while in care
Staff left resident unattended for extended periods of time
INVESTIGATION FINDINGS:
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On 4/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220218123922. LPA Han met with assistant administrator, Robert Sarison and the administrator, Edwina Tang joined shortly thereafter. LPA explained the purpose of the visit.

Regarding to allegation of- due to lack of supervision resident sustained several falls while in care and staff left resident unattended for extended periods of time. During the initial reporting, the reporting party stated that resident #1 (R1) was left unattended, fell multiple times, sustained injuries and the facility provided a flu shot to R1 without the responsible party's consent. There was no additional information forthcoming from the reporting party other than the initial reporting.


Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 14-AS-20220218123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RESIDENCES
FACILITY NUMBER: 385601084
VISIT DATE: 04/21/2022
NARRATIVE
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During the initial 10-day complaint inspection on 2/28/2022, LPA observed R1 was in the Terrace room passively participating in an activity in the presence of an activity staff, R1's private caregiver and a few other residents.

LPA interviewed the facility directors who denied this allegation. LPA interviewed 4 facitliy staff who provided care to R1 and they reported that R1 was not left unattended, R1 did not fall and sustained injuries.

LPA observed the LIC624- Incident Reports from Jan 2022 and there was not reporting of R1 falling.

Concerning facility administered a flu shot to R1 without R1's responsible party's written consent. The administrator acknowledged the flu shot was given without a consent. Therefore, this deficiency will be cited on a LIC809.

Base on record review and interviews during the course of investigation, this allegation is unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with the facility administrator.

A copy is provided.

SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/18/2022 and conducted by Evaluator Murial Han
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20220218123922

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: 106DATE:
04/21/2022
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:administrator and assistant administratorTIME COMPLETED:
03:05 PM
ALLEGATION(S):
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Staff failed to return resident's personal belongings
INVESTIGATION FINDINGS:
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 On 4/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220218123922. LPA Han met with assistant administrator, Robert Sarison and the administrator, Edwina Tang joined shortly thereafter. LPA explained the purpose of the visit.

Regarding to allegation of staff failed to return resident's personal belongings- during the initial reporting, the reporting party stated that the resident #1 (R1)'s personal belongings (briefs, wheelchairs, supplies, diapers, etc) were consistently missing from R1's room and the reporting party strongly believes staff removes R1's belongings and gives it to other residents. However, there was no additional information forthcoming from the reporting party.

LPA interviewed 4 facility staff who provide care to R1 and all of them stated that they were not aware that R1 was missing personal belongings from R1's room and they also reported that the facility has back-up supplies such as wheelchairs, diapers so there was no need to use other resident's supplies.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 14-AS-20220218123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RESIDENCES
FACILITY NUMBER: 385601084
VISIT DATE: 04/21/2022
NARRATIVE
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LPA interviewed the facility director who denied the allegation.

Based on interviews and observation during the course of the investigation, this allegation was deemed to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

This report is discussed and reviewed with the administrator and the assistant administrator.

A copy is provided.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 14-AS-20220218123922
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 RESIDENCES
FACILITY NUMBER: 385601084
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/21/2022
Section Cited
CCR
87468.1(a)(3)
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87468.1 Personal Rights...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse....
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When the facility discovered this incident, the facility immediately removed this former staff from the work, reported to the proper departments and investigated the incident.
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This requirement was not met as evidenced by: the facility failed to ensure R1 was free from punishment and abuse as R1 was handled roughly by a former staff who grabbed R1 and R1 sustained an injury which posed an immediate health and safety risks to resident in care.
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After the investigation, the staff never returned to work and the facility provided training on Elder Abuse and submitted a copy of the in-service record to LPA during the initial 10-day complaint visit. Therefore this deficiency is cleared.
Deficiency Dismissed
Type A
04/25/2022
Section Cited
CCR
87464(f)(1)
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87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code
section 1569.2(c).
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The administrator and/or designee will provide training to facility staff on care and supervision and provide a copy of the sign-in sheet to CCL by the plan of correction due date 4/25/2022.
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This requirement was not met as evidenced by: there was no care and supervision provided when R2 and R3 were watching TV in the TV room which posed an immediate health and safety risks to resident in care.
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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.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 04/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022
LIC9099 (FAS) - (06/04)
Page: 7 of 7