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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 385601084
Report Date: 09/19/2023
Date Signed: 09/19/2023 11:57:12 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
03/07/2023 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230307165826
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: 155DATE:
09/19/2023
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Rob Sarison and Edwina TangTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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------------This report is an amendment of original Complaint Investigation Report dated 6/30/23---------

Facility admitted a resident without consent
INVESTIGATION FINDINGS:
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Based on review of client and facility records and interviews with staff, witnesses, as well as resident, this allegation is determined to be substantiated.

Former client #1 was admitted to facility on 11/4/21 directly from SNF, after sustaining a hip fracture. Placement into the memory care unit with delayed egress was facilitated by client's Durable Power of Attorney and deemed to be the most appropriate, considering client's safety and risk assessment. In addition to client's physical condition, she exhibited poor judgement, increased confusion and risky behaviors prior to the injury. Client did not object to admission to RCFE. However, she did not provide verbal or written consent of admission to memory care unit with delayed egress.

Deficiency of the California Code of Regulations, Title 22 is cited on a following page.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2023
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 2
Control Number 14-AS-20230307165826
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
10/03/2023
Section Cited
HSC
1569.698(f)
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Any person who is not a conservatee and is entering a locked or secured perimeter facility pursuant to this section shall sign a statement of voluntary entry. The facility shall retain the original statement and shall send a copy of the statement to the department.
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Plan of correction to be submitted by DUE DATE
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This requirement was not met, as client #1 was not conserved and did not sign a statement of voluntary entry into facility's memory care unit. Licensee failed to obtain written consent from client #1 upon admission to memory care unit with delayed egress, which posed a potential health, safety or personal rights risk to clients 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: Cara Smith
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 09/18/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/18/2023
LIC9099 (FAS) - (06/04)
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