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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 10/09/2020
Date Signed: 10/09/2020 07:55:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:HOPKINS MANOR PACIFIC CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(415) 806-4069
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: DATE:
10/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Travis Wyckoff andTIME COMPLETED:
05:30 PM
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On 10/9/20, at 1:45 PM, Licensing Program Analyst Mohamed Filouane, conducted a case management, health and safety visit. LPA met with a staff member at the front entrance and was scanned for temperature and asked questions regarding COVID19 symptoms. LPA Filouane then met with Licensee Travis Wyckoff and explained the purpose of the visit.

At 1:55 PM, LPA Filouane sat at a table outside the facility with the Licensee and reviewed the staff roster and schedule. LPA also verified the resident roster, identified the positive and negative residents, identified the residents residing in the facility and the residents residing in hospitals.

At 3:00 PM, LPA Filouane delivered the PPE supplies from the LPA's vehicle to the Licensee's facility.

At 3:15 PM, LPA Filouane conducted a tour of the facility with the Licensee. LPA toured the second floor, which is the main floor of the facility, and it has eleven residing residents. The second floor also has a table of PPE supplies and a dining room that is not being used by residents. The dining room, at the time of the LPA's tour, was being used for a meeting for infection prevention control. At 3:30 PM, LPA Filouane toured the third floor of the facility, which has a total of twenty-two rooms, with eleven rooms occupied, and eleven rooms vacant. All rooms on the third floor are occupied by COVID19 positive residents. At 3:45 PM, LPA then toured the first floor of the facility, where one resident resides.

At 4:00 PM, LPA returned to the Licensee's office to review information and write this report. This report was reviewed and discussed with Administrator Roz Wyckoff. No citations were issued during this health and safety visit.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Mohamed FilouaneTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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