Lynne & Roy M Frank Residences

Type of visit: Case Management - Incident

On 9/16/2026, Licensing Program Analysts (LPA) Yi Sam Jian arrived unannounced for the purpose of conducting a case management. The purpose of the case management is to address the following incidents reported: 1) Suspected Abuse Report (SOC341) dated 8/27/2026; 2) incident report dated 9/01/2026; 3) incident report dated 01/21/2026; 4) incident report dated 7/13/2026. LPA met with administrator, Gloria Vo, and explained the purpose of the visit. Facility reported four resident incidents involving falls with injuries requiring medical evaluation, unsafe driving with altered mental status, and suspected financial abuse. Facility reported providing emergency response, medical follow-up, notifications, and monitoring. LPA interviewed staff and reviewed resident and staff records. No deficiencies were cited during this visit. The Department may conduct further follow-up as warranted. The report was reviewed with the Administrator, and a copy was left at the facility.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Required - 1 Year

On 09/16/2026 Licensing Program Analyst(LPA) Yi Sam Jian arrived at the facility to conduct the Annual 1-year required visit. LPA was greeted by administrator, Gloria Vo 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. 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.the state’s words, verbatim · CDSS document, Sep 16, 2026

Type of visit: Case Management - Incident

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 the 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.the state’s words, verbatim · CDSS document, Mar 11, 2026

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 Unsubstantiated 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.the state’s words, verbatim · CDSS document, Feb 4, 2026 · control 14-AS-20251023091002

Type of visit: Case Management - Other

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 explained 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 reviewed 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.the state’s words, verbatim · CDSS document, Sep 5, 2025

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Aug 14, 2025

Type of visit: Case Management - Other

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.the state’s words, verbatim · CDSS document, Jun 5, 2025

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. Unsubstantiatedthe state’s words, verbatim · CDSS document, Mar 19, 2025 · control 14-AS-20241113155247

Type of visit: Required - 1 Year

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.the state’s words, verbatim · CDSS document, Sep 19, 2024

Type of visit: Case Management - Incident

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.the state’s words, verbatim · CDSS document, Aug 9, 2024

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. Unsubstantiated 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.the 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 visiting nurse assessments, the wounds healed within 6 weeks. ......Continued Substantiated Staff training records for 3 caregivers in memory care unit 3 are reviewed today. This does not include one agency staff, for which there is no information about what dementia training was received. Two staff were required to have at least 12 hours of dementia specific training, as part of initial training. One caregiver was required to have at least 8 hours of dementia specific training, as part of annual continuing training. There is no documentation to verify that two new staff received 12 hours of dementia specific training, and there was documentation of just 5.5 hours of annual continuing dementia training for one caregiver. Deficiencies of the California Code of Regulations, Title 22 are cited on a following page.the state’s words, verbatim · CDSS document, Mar 25, 2024 · control 14-AS-20230711162135

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Apr 8, 2024

OBSERVATION OF THE RESIDENT The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs... the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement was not met, as client #1 did not receive timely medical intervention when pressure ulcers were observed, which poses a potential health, safety or personal rights risk to clients.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468.1(a)(8) · Plan of correction due date: Apr 8, 2024

PERSONAL RIGHTS OF RESIDENTS IN ALL FACILITIES Residents in all RCFEs shall have...the following personal rights: To have their representatives regularly informed by the licensee of activities related to care or services, including ongoing evaluations, as appropriate to their needs. This requirement was not met, as responsible parties of client #1 were not notified when staff observed pressure injuries on client #1. Licensee failed to ensure that responsible parties of client #1 received timely report that pressure injuries were observed, which posed a potential health, safety or personal rights risk to clients.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(1) · Plan of correction due date: Apr 8, 2024

This training shall consist of 40 hours... A staff member shall complete 20 hours, including 6 hours specific to dementia care, as required by subdivision (a) of Section 1569.626 ...before working independently with residents. The remaining 20 hours shall include 6 specific to dementia care and shall be completed within the first four weeks of employment. This requirement was not met, as there is no evidence that staff #2 and #3--who were hired 4/23 and 12/22 respectively--received at least 12 hours of dementia specific training, which posed a potential health, safety or personal rights risk to clients.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE

From the deficiency page — Deficiency type: Type B · Section cited: HSC 1569.625(b)(2) · Plan of correction due date: Apr 8, 2024

...training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626... This requirement was not met, as there is no documentation that staff #1, who was hired 5/22, received at least 8 hours of dementia specific training. Licensee failed to ensure that staff received required annual dementia training, which posed a potential health, safety, or personal rights risk to clients in care.the state’s words, verbatim · CDSS document, Mar 25, 2024

Plan of correction: Plan of correction to be submitted to CCLD BY DUE DATE