Lynne & Roy M Frank Residences

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

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.698(f) · Plan of correction due date: Oct 3, 2023

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. 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.the state’s words, verbatim · CDSS document, Sep 19, 2023

Plan of correction: Plan of correction to be submitted by DUE DATE

Allegation investigated: Resident was left in the soiled diaper for extended period of time. Resident needs not being met. Facility is short staffed.

Based on review of facility's client records--including care plan and care notes--caregivers' schedules from May to July 2022, observations made on 7/8/22 and 6/30/23, and interviews with staff and witnesses, these allegations are determined to be unsubstantiated. Caregivers are assigned to care for up to 5 memory care clients, and complete a daily assignment form to record personal care--including bathing/showering, dressing/grooming, skin care, toileting, showering, status checks and nutrition--and other comments. At the end of the shift, caregivers log meal intake %, bowel movement, and showers--yes, no, refused--on the client's monthly ADL Report Log. Med techs review the daily assignment forms and identify highlights and/or concerns. According to staff, client #1 was checked regularly to ensure that his pull-ups were dry. This was in accordance with facility Care Plan, which specified that staff were to check and assist client with toileting needs every 2 hours. Documentation of these checks was not maintained, so there is no record of when or how often staff checked or assisted with toileting. That client wore a soiled diaper for an extended period of time cannot be proven nor disproven. Unsubstantiated 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.the state’s words, verbatim · CDSS document, Jul 10, 2023 · control 14-AS-20220705125146

Allegation investigated: - Facility not allowing resident to leave facility

Based on review of client and facility records and interviews with staff, witnesses, as well as resident, this allegation is determined to be unsubstantiated. Nine months after admission, local Ombudsman responded to client's request for assistance to return to her private residence and met with resident and staff. According to staff, client repeatedly expressed her desire to go home, but would be easily redirected. Two months later, in October 2022, DPOA met with staff and Ombudsman to review the appropriateness of client's placement and assess whether or not she was able to go home. Client's home was not suitable to ensure client's safety, and staff planned to further engage client in activities suited for her interests until she could be relocated. The Ombudsman had no concerns that client was forced to remain in facility against her will. Unsubstantiated 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 documents, 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.the state’s words, verbatim · CDSS document, Jun 30, 2023 · control 14-AS-20230307165826

Allegation investigated: - Resident was physically attacked by another resident - Staff did not provide food of the quality or quantity to meet needs of residents - Staff did not meet resident's incontinence needs - Staff did not meet resident's hygiene needs - Resident's room is not properly cleaned by staff

On this day Licensing Program Analyst (LPA) conducted an unannounced complaint investigation visit in order to deliver the findings for the above allegations. LPA met with executive director Edwina Tang and assistant executive director Robert Sarison. LPA explained the purpose of today's visit. During the course of the investigation LPA conducted interviews with staff, made facility observations, interviewed resident family members, outside agencies, and reviewed pertinent documents. LPA could not reach a preponderance of evidence standard to substantiate any of the allegations received as conflicting information and one party's word over another, could not aid in the determination of any of the allegations. These allegations are unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. 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 above allegations are unsubstantiated at this time. Report is reveiwed with executive director Edwina Tang. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 12, 2023 · control 14-AS-20220323142722

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, May 12, 2023

Type of visit: Case Management - Incident

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. 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.the state’s words, verbatim · CDSS document, Dec 5, 2022

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87303(a) · Plan of correction due date: Dec 6, 2022

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 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.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: The facility will develop a plan to ensure all the delayed egress door(s) at the facility is routinely checked and document the outcomes. The administrator will submit a copy of the plan to CCL by 12/6/2022. Plan of correction cleared.

From the deficiency page — Deficiency type: Type B · Section cited: CCR87705(c)(3)(A) · Plan of correction due date: Dec 6, 2022

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,.. 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.the state’s words, verbatim · CDSS document, Dec 5, 2022

Plan of correction: 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. Plan of correction cleared.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Sep 30, 2022

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Sep 30, 2022

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Jul 1, 2022

Allegation investigated: Staff handled resident in a rough manner Resident sustained injuries while in care Facility has insufficient staffing to meet residents' needs

On 4/21/2022, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of complaint # 14-AS-20220218123922. LPA Han met with assistant administrator, Robert Sarison and the administrator, Edwina Tang joined shortly thereafter. LPA explained the purpose of the visit. Regarding allegation of- staff handled resident in a rough manner and resident sustained injuries while in care, during the initial reporting, the reporting party stated that a male staff grabbed resident #1 (R1)'s arm that caused R1 to sustain injuries. According to the administrator, when the facility learned about the above incident, the facility immediately removed the male staff from work, reported the incident to CCL, Ombudsman and conducted investigation. After the investigation, the male staff did not return to work and the facility provided Elder Abuse in-services to facility staff. Based on record review, and interviews during the course of investigation, this allegation is substantiated. Substantiated Regarding to allegation of facility has insufficient staffing to meet residents' needs- during the initial 10-day complaint inspection on 2/28/22 at 11:15am, LPA and the assistant administrator entered the TV / Dinning room in Memory Care Unit 3B, LPA observed resident #2 (R2) and resident #3 (R3) were watching TV by themselves. Then, LPA observed a staff was going in and out of the kitchen that is located in the dinning room and the dinning is in the same room as the TV room but separated by a wall. LPA observed the staff who was going in and out of the kitchen did not have visual supervision of both residents as the wall was in between the 2 rooms. A few minutes later the same staff completed his/her tasks in the kitchen and left the dinning/ TV room while both residents continued to watch TV in the TV room. Based on observation and interview during the course of the investigation, this allegation is substantiated. Based on observation and interview during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator, and Appeal Rights provided. A copy of this report is provided. During the initial 10-day complaint inspection on 2/28/2022, LPA observed R1 was in the Terrace room passively participating in an activity in the presence of an activity staff, R1's private caregiver and a few other residents. LPA interviewed the facility directors who denied this allegation. LPA interviewed 4 facitliy staff who provided care to R1 and they reported that R1 was not left unattended, R1 did not fall and sustained injuries. LPA observed the LIC624- Incident Reports from Jan 2022 and there was not reporting of R1 falling. Concerning facility administered a flu shot to R1 without R1's responsible party's written consent. The administrator acknowledged the flu shot was given without a consent. Therefore, this deficiency will be cited on a LIC809. Base on record review and interviews during the course of investigation, this allegation is unsubstantiated. Although the above investigations 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 allegation is UNSUBSTANTIATED. Exit interview conducted with the facility administrator. A copy is provided. LPA interviewed the facility director who denied the allegation. Based on interviews and observation during the course of the investigation, this allegation was deemed to be unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. This report is discussed and reviewed with the administrator and the assistant administrator. A copy is provided.the state’s words, verbatim · CDSS document, Apr 21, 2022 · control 14-AS-20220218123922

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(3) · Plan of correction due date: Apr 21, 2022

87468.1 Personal Rights...(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:(3) To be free from punishment, humiliation, intimidation, abuse.... This requirement was not met as evidenced by: the facility failed to ensure R1 was free from punishment and abuse as R1 was handled roughly by a former staff who grabbed R1 and R1 sustained an injury which posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: When the facility discovered this incident, the facility immediately removed this former staff from the work, reported to the proper departments and investigated the incident. After the investigation, the staff never returned to work and the facility provided training on Elder Abuse and submitted a copy of the in-service record to LPA during the initial 10-day complaint visit. Therefore this deficiency is cleared.

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Apr 25, 2022

87464(f)(1) Basic Services(f)- Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by: there was no care and supervision provided when R2 and R3 were watching TV in the TV room which posed an immediate health and safety risks to resident in care.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: The administrator and/or designee will provide training to facility staff on care and supervision and provide a copy of the sign-in sheet to CCL by the plan of correction due date 4/25/2022.

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Apr 21, 2022

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: May 5, 2022

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... 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.the state’s words, verbatim · CDSS document, Apr 21, 2022

Plan of correction: 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. 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.

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Sep 20, 2021