Lynne & Roy M Frank Residences

On 03/11/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted a case management incident visit at the facility regarding a self-reported incident involving an allegation of rough handling of resident R1 by staff S1. LPA met with Assistant Administrator, Gloria Vo and explained the purpose of the visit. During today’s visit, LPA conducted interviews with facility staff and collected documentation related to th e incident. LPA also reviewed facility documentation related to the incident report and the facility’s response. The Department will continue to review the information obtained . Additional follow-up may be conducted as needed. No deficiencies were cited during today’s visit. Report was reviewed with Assistant Administrator and a copy was provided.

Regarding the allegation that staff did not prevent residents from eloping from the facility, the Department conducted investigation. Interviews with residents did not indicate that residents left the facility without staff awareness or supervision. Facility records reviewed did not document any resident elopement incidents. Regarding the allegation that staff left residents in soiled diapers for a long period of time, the Department conducted investigation. Interviews with residents did not support the allegation, and residents did not report being left in soiled diapers or clothing. No documentation or additional evidence was obtained to corroborate the allegation. Regarding the allegation that staff are not following residents’ dietary plans, the Department conducted investigation. Document review and resident interviews did not identify evidence that residents’ dietary plans were not being followed. Residents interviewed did not report concerns regarding meals inconsistent with their dietary needs. The complaint alleged that client C1 was administered medications that did belong to another individual. The LPA determined there was conflicting information indicating that C1 did not reside at the facility, and there was insufficient corroborating evidence to substantiate the allegation. Although the above allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated. An exit interview was conducted. This report is reviewed and a copy this report is provided to the administrator.

On 09/05/2025 Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit to follow up on a death report submitted on 09/03/2025. LPA met with administrator Robert Sarison, purpose of the visit e xplained to administrator. The facility reported that on September 3, 2025, Resident R1 passed away and the immediate cause of death was not disclosed. According to the death report submitted to Community Care Licensing (CCL), on August 31, 2025, at approximately 6:45 AM, Licensed Vocational Nurse (LVN) S1 found Resident R1 unresponsive and lying in a pool of emesis on the bed. S1 initiated CPR but was unable to revive the resident. Emergency services were called, and paramedics arrived and pronounced R1 deceased at the scene. During today’s visit, LPA revie wed and collected relevant documentation and conducted interviews with director of health and wellness S2. S1 was not available for interview at the time of the visit. The administrator stated that the facility will request a copy of the official death certificate once it becomes available. No citations issued. Report discussed with administrator.

On 08/14/2025 Licensing Program Analyst(LPA) Yi Sam Jian arrived at the facility to conduct the Annual 1-year required visit. LPA was greeted by administrator, Robert Sarison and explained the purpose of the visit. LPA toured facility and grounds, consisting of studio, 1-bedroom and 2-bedroom units on 5 floors. 1st floor had Assisted living rooms, kitchen, common use rooms for the assisted living residents--lounges, dinning rooms, theater, performance center, cafe, salon, and fitness center, including locked indoor pool. 2nd, 3rd, 4th floor had assisted living room and memories care rooms. 5th floor had assisted living rooms only. In each of the memory care units, there is at least one dedicated dining room and outdoor space. The building accommodates residents, including non-ambulatory, and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. Basement parking lead to emergency generator. 2 outdoor courtyards, accessible from 1st floor, had no accessible body of water. Kitchen and food supplies are inspected. Infection control practices are reviewed. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, hot water temperature inspected to be compliant, and lighting is sufficient for comfort and safety. Fire safety equipment checked and fully charged. Facility van's first-aid kit and fire extinguisher inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. No deficiency cited today. The report is reviewed with administrator and a copy is provided.

On this day Licensing Program Analyst (LPA) Yi Sam Jian conducted an unannounced case management visit to deliver an amended complaint report. LPA met with Gloria Vo - Assistant Executive Director during today's visit. LPA explained the amended report delivery and the reason it was amended. She confirmed that she understood the amended report. No citations issued. Report reviewed with Assistant Executive Director.

LPA Yi Sam Jian and Dominic Tobola toured facility and grounds, consisting of studio, 1-bedroom and 2-bedroom units on 5 floors. 1st floor had Assisted living rooms, kitchen, common use rooms for the assisted living residents--lounges, dinning rooms, theater, performance center, cafe, salon, and fitness center, including locked indoor pool. 2nd, 3rd, 4th floor had assisted living room and memories care rooms. 5th floor had assisted living rooms only. In each of the memory care units, there is at least one dedicated dining room and outdoor space. The building accommodates residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. 2 outdoor courtyards, accessible from 1st floor, had no accessible body of water. Kitchen and food supplies are inspected. Infection control practices are reviewed. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, hot water temperature inspected to be compliant, and lighting is sufficient for comfort and safety. Fire safety equipment checked and fully charged. Facility van's first-aid kit and fire extinguisher inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. No deficiency cited today. The report is reviewed with administrator Edwina Tang and a copy is provided.

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.

LPA interviewed four staff members. All mentioned that there is no issue with regards to staffing in the facility. A staff, S3, mentioned that if there are call outs it still gets covered. Staff are also able to manage feeding without issues. Each staff interviewed has 4 to 5 residents assigned under their care. S2 also mentioned that if needed, calls another person for additional assistance. During the interview, S1 also mentioned that there is a resident (R1), has been slow in responding and can't balance anymore, eats a little bit and slowly eats or chews. S2 also confirmed that R1 is a non-verbal resident, a slow eater and has difficulty in feeding. R1 used to attend activities before and sometimes participates depending on the condition. S5 stated that there are floaters who can work both in memory care and assisted living. They are cross trained in case needed. Based on records review, the facility provided the schedule in memory care unit there is currently 4 neighborhoods where residents live. For each neighborhood there are two to three caregivers (depending on the number of residents). Aside from that there is also a nurse on shift, three med techs, two floaters and activity coordinators. LPA also checked the progress notes and meal logs for R1 and it showed that R1 is eating less and less. Records also show that facility reached out to responsible party regarding R1’s slow decline and referral to hospice. Based on interviews & records review, the department has determined that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED. Report is reviewed and copy is provided.

As per November 2021 care plan for client #1, he was to receive assistance with showers 3 times per week. Upon review of facility's ADL Reports Logs for May, June, July 2022, caregivers assisted client to shower 3 times in May, 6 times in June, and 7 times in July, and he refused to shower at least 4 times. LPA was advised that when client refused to shower, a sponge bath was offered as an alternative, but not documented by staff. It cannot be confirmed that client's needs were not met by staff. Based on review of memory care units staffing in May, June, July 2022, no staff shortages were apparent. In July 2022, there were 43 clients residing in 4 memory care units/neighborhoods. AM shift averaged 6.57 caregivers in May, 6.58 in June, and 6.93 in July; PM shift averaged 6.64 caregivers in May, 6.23 in June, and 7.2 in July; NOC shift averaged 5.25 caregivers in May, 6.0 in June, and 6.03 in July. Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

Following the October meeting, DPOA arranged to have client's private home cleaned and set up for safety. This included sorting through mail, tax and financial docume nts, unpaid bills, clearing dirty laundry, clothing and clutter, as well as retaining a private care manager and hiring and scheduling 24 hour companions. Pre-placement appraisal completed prior to client's RCFE admission states that client has poor short-term memory and confusion. Facility's care plan identified that client was disoriented, forgetful and repetitious. As per MD reports dated 10/27/21--prior to admission--1/31/23, and 2/9/23, client has mild cognitive impairment and prior alcohol dependency. Most recent MD report states that 24 hour monitoring is needed due to intermittent confusion. Former resident acknowledged that in order for her to return home, she had to be fully able to access and manage the stairs in and outside her private residence. When she recovered from her injury, she expressed her desire to return home, and Ombudsman was instrumental in facilitating this in March 2023, with 24 hour companions. Her personal right to leave facility was not violated and the length of time she lived at facility was not a concern. Due to client's intermittent confusion, forgetfulness and short-term memory loss, this allegation cannot be determined to be substantiated or unfounded. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - other visit to discuss admission policies of the facility. LPA met with executive director Edwina Tang and assistant executive director Robert Sarison. LPA explained the purpose of today's visit. The facility does have admission policies and practices regarding determining responsible party for admission. LPA was provided a copy of the current admission practices for memory care. Per the facility placement in the facility is determinant on who is the responsible person for the resident being admitted in. It was discussed that the facility does work with the family member(s) on who is responsible for the placement. If the resident does have a durable power of attorney (DPOA) they rely on the documentation received. The facility is continually adjusting the admission practices and is in the process of updating the admissions policy for clarity and to ensure that the facility is taking the right steps in regards to resident admission practices. Report is reviewed with the executive director Edwina Tang. No citations are issued.

LPA Jeung met with executive director and obtained information about COVID cases that were reported to CCLD by email on 9/22/22. There are no new staff or residents infected with COVID. LPA also toured facility as part of annual inspection. See Facility Evaluation Report (LIC809). Staff work schedule for the week and client rosters by name and room number are given to LPA. No deficiencies observed today.

LPA Audrey Jeung toured facility and grounds, consisting of studio, 1-bedroom and 2-bedroom units on 5 floors. Currently, the 4th floor memory care unit is vacant. There are residents in the third floor memory care unit--where there are 30 units--and part of the 2nd floor memory care unit. All are equipped with 30 second delayed egresses: one is tested and operates as required. In each of the memory care units, there is at least one dedicated dining room and outdoor space. The rest of the building accommodates assisted living residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room for assisted living residents on the ground level, which accesses an outdoor courtyard. On the ground floor, there are common use rooms--lounges, theater, performance center, cafe, salon, and fitness center, including indoor pool. Kitchen and food supplies are inspected. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap is available in common bathrooms and private bathrooms of assisted living bathrooms. Handwashing reminder signs are posted appropriately. Staff and residents are checked daily for COVID symptoms and temperature checked and documented. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Edwina Tang is a certified RCFE administrator (x 11/23) that oversees facility operations. The following updated licensing forms or information are requested to be submitted to CCLD BY 10/10/22: - Administrative Organization (LIC309) - Personnel Report (LIC500) - Proof of liability insurance Infection Control Plan is provided to LPA today. This may have been submitted to CCLD previously. No deficiencies of the CA Code of REgulations, Title 22 are observed. FAcility is operating in substantial compliance with Title 22 RCFE regulations. See Technical Advisory Note for additional information.

LPAs Jeung and Varilla met with assistant executive director and director of health and wellness to obtain details of incident of 6/11/22 that was reported to CCLD. LPAs reviewed file for client #1 and private companion, who was removed from facility on 6/11/22. LPAs were advised that SF Ombudsman met with facility staff, private companion, and daughter of client to discuss incident. As a result--and based on wishes of DPOA/daughter--private companion is allowed to resume companionship to client as of 6/17/22. Private companion was provided with training by hospice agency on feeding strategies on 6/23/22. Facility documents for private attendants--acknowledgement, indemnification, guidelines--were signed by private companion; copies are obtained. Requirements for Private Duty Attendants and Home Health Agency Personnel and Rules of Conduct of Attendants are also reviewed, but it cannot be confirmed that these documents were given to or acknowledged by private companion of client #1. LPAs recommended that Personal Rights forms LIC613C/LIC613C2 be added to forms that private attendants be required to acknowledge when providing services to facility. No deficiency cited.

LPA Audrey Jeung toured facility and grounds, consisting of studio, 1-bedroom and 2-bedroom units on 5 floors. Thirty rooms comprise the memory care unit on the third floor, where there are 4 exits equipped with a 30 second delayed egress: one is tested and operates as required. This unit has 2 small dining rooms and an outdoor patio. There are 2 additional memory care units that are not yet in use--on the 2nd and 4th floors. The rest of the building accommodates assisted living residents, including non-ambulatory, bedridden and hospice residents. Rooms are equipped with emergency call systems, which can be activated from bathrooms and bedrooms. There is a large dining room for assisted living residents on the ground level, which accesses an outdoor courtyard. On the ground floor, there are common use rooms--lounges, theater, performance center, cafe, salon, and fitness center. The pool is not yet available to residents. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is adequate. Medications, toxins and sharps are stored appropriately and inaccessible to clients, a comfortable temperature is maintained, and lighting is sufficient for comfort and safety. Liquid soap is available in common bathrooms and private bathrooms of assisted living bathrooms. First-aid kit is inspected and complete. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Edwina Tang is a certified RCFE administrator (x 11/21) that oversees facility operations. The following updated licensing forms or information are requested to be submitted to CCLD BY 9/27/21: - Board Resolution designating Ms. Tang as facility administrator - Personnel Report (LIC500) - Proof of liability insurance - Written notification of facility public phone number and email address (to receive CDSS notifications) COVID Mitigation Plan is provided to LPA today. This may have been submitted to CCLD previously. No deficiencies of the CA Code of REgulations, Title 22 are observed. FAcility is operating in substantial compliance with Title 22 RCFE regulations.

LPA requested and obtained the letter from the responsible party requesting to deny visitation and communication with the family member, the LIC 601, as well as emails from facility staff to facility management reporting about the event on 05/26/21. Although the allegations 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 allegations are UNSUBSTANTIATED. This report was reviewed and discussed with the Executive Director. This report will be emailed to the Executive Director due to technical difficulties.