Lynne & Roy M Frank Residences

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: -Staff are not bathing residents in care -Staff administered a medication that was not prescribed to a resident in care -Staff did not prevent residents from eloping from the facility -Staff left residents in soiled diapers for a long period of time -Staff are not following residents dietary plans

On 02/04/2026, Licensing Program Analyst (LPA) Yi Sam Jian conducted an unnannounced complaint visit. LPA met with Assistant Administrator, Gloria Vo, Administrator, Robert Sarison. LPA explained the purpose of the visit. Regarding the allegation that staffs are not bathing residents in care, the Department conducted investigation. Interviews with residents from each floor of the facility did not reveal concerns regarding lack of bathing. Upon review facility records, LPA was unable to find corroborating evidence supporting the allegation. Regarding the allegation that staff administered a medication that was not prescribed to a resident in care, the Department conducted investigation. Medication Administration Records (MARs) for residents in care were reviewed and did not identify evidence that residents were administered medications without a physician’s order. Residents interviewed did not report receiving incorrect medications. CONT TO 9099C Unsubstantiatedthe state’s words, verbatim · CDSS document, Feb 4, 2026 · control 14-AS-20251023091002

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: - Due to Lack of Care and Supervision Resident sustained pressure injuries - Reporting requirement

THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 03/19/2025. REPORT AMENDED TO CHANGE FINDINGS. On 06/05/2025, Licensed Program Analyst (LPA) Yi Sam Jian arrived at the facility to deliver an amended copy of LIC9099. LPA met with administrator Gloria Vo - Assistant Executive Director and explained the purpose of the visit. Regarding the allegations of resident sustained pressure injuries due to Lack of Care and Supervision and reporting requirement. The facility provided documentation demonstrating the care and supervision provided to the resident, along with records of communication with the reporting party regarding the resident’s condition. Although the 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 was reviewed with the Assistant Executive Director and a copy of the report left at the facility.the state’s words, verbatim · CDSS document, Mar 19, 2025 · control 14-AS-20241113155247

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Licensee does not ensure sufficient staffing to meet residents’ care needs

On 8/8/24, Licensing Program Analyst (LPA) Grace Donato conducted an unannounced complaint investigation visit. LPA met with Sandra Peret, Edwina Tang, Rob Sarison and explained the purpose of today's visit. Regarding the allegation of Licensee does not ensure sufficient staffing to meet residents’ care needs., Reporting Party (RP) stated that the residents in the memory care unit, especially those who cannot speak, are being neglected by staff because the facility is short staffed, so the residents’ care needs are not being met. RP states the residents are often left in their rooms and forgotten about. LPA was able to interview RP, and an additional information was provided stating that a resident (R1) who stays in memory care always sleeps in the room and doesn't get fed. You can tell every time you go that there is not enough staff. Sometimes the caregivers who are in memory care goes to assisted living. Unsubstantiatedthe state’s words, verbatim · CDSS document, Aug 8, 2024 · control 14-AS-20240716165634

Allegation investigated: - Licensee neglect resulted in resident developing pressure injuries - Staff did not report pressure injuries to resident's responsible party - Staff not properly trained in dementia care

LPA Jeung reviewed staff training records. Based on review of facility records--including Clinical Notes, Care Plan, ADL Report Logs, correspondence and staff training transcripts--as well as interviews with staff, these allegations are determined to be substantiated. The preponderance of evidence standard has been met. On May 2, 2023--ten days after testing positive for COVID and isolating in his room--client #1 was observed by caregiver with pressure injuries. Two pressure injuries on the coccyx were subsequently observed by visiting family member two days later and reported to facility staff the following day. Client's physician was immediately consulted when assistant director of health and wellness became aware of the injuries, and a plan of care was implemented for the stage I and stage II pressure ulcers, including home health nursing. Earlier observation by staff during assistance with personal care could have resulted in more timely medical intervention. According to visitingthe state’s words, verbatim · CDSS document, Mar 25, 2024 · control 14-AS-20230711162135

Allegation investigated: ------------This report is an amendment of original Complaint Investigation Report dated 6/30/23--------- Facility admitted a resident without consent

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. Substantiatedthe state’s words, verbatim · CDSS document, Sep 19, 2023 · control 14-AS-20230307165826