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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 385601084
Report Date: 12/05/2022
Date Signed: 12/05/2022 11:25:23 AM

Document Has Been Signed on 12/05/2022 11:25 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
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: 122DATE:
12/05/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Administrator, Edwina TangTIME COMPLETED:
11:35 AM
NARRATIVE
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On 12/5/2022, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to follow up on an incident that was reported by the facility.

On 11/4/2022, facility reported resident #1 (R1) eloped through the delayed egress door, took stairwell and was found by staff on the 5th floor roof top.

On 11/7/2022, the assistant administrator stated that R1 resides in the 3rd floor memory care unit and exited through the delayed egress door which triggered the alarm and subsequently the over head paging system announcing that the delayed egress door was opened. Staff witnessed the door opened which triggered a head-count and discovered R1 was missing. Staff started searching, and found R1 on the 5th floor roof and escorted R1 back to the unit. The assistant administrator also stated that the delayed egress door is 30 seconds delayed.

On 11/7/2022, LPA inquired about staff response time after the alarm went off as the delayed egress door is 30 seconds delayed to prevent elopement while maintaining life safety. The administrator stated that during the incident, the delayed egress door was malfunctioned, therefore, the door opened right away and staff did not check the stairwell that is outside of the door.

In addition, the administrator stated that the delayed egress door was routinely checked but there was no documentation provided of such checks. However, since the incident, the door was repaired and during the repair, a staff was assigned 24 hours a day to monitor the door/exit until it was fixed. In addition, the facility started to document the preventive maintenance checks twice a day.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 RESIDENCES
FACILITY NUMBER: 385601084
VISIT DATE: 12/05/2022
NARRATIVE
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During today visit, LPA and the administrator checked the delay egress door which was properly functioning and staff responded to the alarm appropriately.

In addition, administrator provided documentation of staff monitoring the delayed egress door and staff in-service sign-in records.

Based on interview, and record review during the course of the investigation, the facility was not able to proof that the delayed egress door was in good repair and staff did not check the stairwell after the door was opened.

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC 809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with administrator. Appeals Rights were given.

A copy of report was provided.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2022
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Document Has Been Signed on 12/05/2022 11:25 AM - It Cannot Be Edited


Created By: Murial Han On 12/05/2022 at 10:46 AM
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: 12/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/06/2022
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation(a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by the delayed egress exit door for the memory care
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The facility will develop a plan to ensure all the delayed egress door(s) at the facility is routinely checked and document the outcomes.
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unit was malfunctioned and R1 eloped the unit throught this exit and was found on the 5th floor roof top which poses an immediately health and safety risk for residents in care.
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The administrator will submit a copy of the plan to CCL by 12/6/2022.

Plan of correction cleared.
Type B
12/06/2022
Section Cited
CCR87705(c)(3)(A)

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87705 Care of Persons with Dementia (c) Licensees who accept..residents with dementia shall be responsible for ensuring the following:.(3) In addition to the on-the-job training requirements..(A) Dementia care including, but not limited to, the environment,..
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The administrator/licensee will provide in-services to staff on the importance of following the facility's protocols when the delayed egress door alarm goes off. The facility will provide a copy of the sign-in records for this in-service.
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This requirement is not met as evidenced by after R1 eloped the unit through the delayed egress door, the alarm went off and the staff did not checked the exit/stairwell that was led to the roof top where R1 was found poses a potential health and safety risks to resident in care.
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Plan of correction cleared.
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:Cara Smith
LICENSING EVALUATOR NAME:Murial Han
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2022


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