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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 04/21/2022
Date Signed: 04/21/2022 02:50:00 PM

Document Has Been Signed on 04/21/2022 02:50 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:TANG, EDWINAFACILITY TYPE:
740
ADDRESS:ONE AVALON AVENUETELEPHONE:
(415) 562-2855
CITY:SAN FRANCISCOSTATE: CAZIP CODE:
94112
CAPACITY: 220CENSUS: 106DATE:
04/21/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator, Edwina TandTIME COMPLETED:
03:05 PM
NARRATIVE
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On 4/21/2022, Licensing Program Analysts (LPAs) Murial Han conducted an unannounced case management visit to deliver the findings in reference to complaint # 14-AS-20220218123922. LPA met with the administrator and explained the purpose of the visit.

According to the reporting party of complaint # 14-AS-20220218123922., the facility administered a flu shot to resident #1 (R1) without R1's responsible party's consent. LPA interviewed the administrator who acknowledged that the facility gave R1 a flu shot without a written consent from the responsible party.

Based on the complaint investigation, the facility failed to ensure a consent is obtained from R1's responsible party prior to administering the flu shot.

Deficient is cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with the administrator.

A copy of this report and the Appeal Rights 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
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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Document Has Been Signed on 04/21/2022 02:50 PM - It Cannot Be Edited


Created By: Murial Han On 04/21/2022 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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 B
05/05/2022
Section Cited
CCR
87464(f)(1)

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Personal Rights of Residents...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(8) To have their representatives regularly informed by the licensee of activities related to care...
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The administrator and/or designee will provide in-service to facility staff on informing and obtaining prior consent from residents and/or responsible party prior to the respective care is rendered.
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This requirement is not met as evidenced by: the facility administered R1's flu shot without a consent from R1's responsible party which posed a potential health and safety risks to residents in care.
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The administrator and/or the designee will submit a copy of the in-service lesson plan and the sign-in sheet to CCL by the plan of correction due date 5/5/2022.

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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.
SUPERVISOR'S 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


LIC809 (FAS) - (06/04)
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