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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/24/2020
Date Signed: 11/24/2020 04:49:33 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:HOPKINS MANOR PACIFIC CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 25DATE:
11/24/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Maria Cantoria Temporary ManagerTIME COMPLETED:
04:00 PM
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On November 24, 2020,Regional Manager Krystall Moore, Licensing Program Manager (LPM) Liza King, Program Analyst (LPA) Ashley Boothe, and DSS Clinical Consultant Helen Shi conducted an announced case management visit via Microsoft Teams at 2pm. The team met with Martha Estalano Administrator, Susan Ladeza Administrator, Executive Director Ricardo Aban, and Temporary Manager Maria Cantoria

The team reviewed Helen's recommendations to the Mitigation Plan. Helen’s recommendations were emailed to Maria.

The team discussed the Infection Preventionist role. LPM stated the request of the RO as previously documented the IP role is to be a specific person who takes the sole responsibility in the facility as one job duty as reflected on the LIC 500. LPM recommended all administrators will take the class and then identify who will carry the job title and follow the scope of work outlined in the job duties and responsibilities the facility is working to draft.
The team discussed the Line List watch residents. Resident one and two have positive change in conditions. Resident three now has a 1:1 caregiver to accommodate her needs. Resident four is experienceing cough and signs of UTI. Home health assessed her this morning and her PCP and responsibility have been notified of her change in condition. Resident five came to visit the facility to collect personal belongings. The facility will need to pack the rest to prepare for pick up, time not yet specified. The PCP has provided the facility a letter documenting a change in condition from the LIC 602 stating resident can administer his own medications and the facility needs to follow up to ensure pick up has been coordinated for tomorrow, administrator stated one voicemail left for resident already.

Ricardo stated testing completed yesterday, itemized on the line list, and results pending.

Continued on 809 C.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: HOPKINS MANOR PACIFIC CORPORATION
FACILITY NUMBER: 415600927
VISIT DATE: 11/24/2020
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Continued from 809.

Administrator stated the are busy doing calls to responsible parties to request permission to move dementia care residents to the main floor. Maria stated she would email a written admissions agreement addendum that needs to be signed prior to moving the residents. The RO requested update facility map or list of resident room assignments be sent to the RO at the time when moves occur.

The team reviewed Documents received from Case Management Visits.
  • LIC 500 with schedule (Received 11/23/2020)
  • Facility sketch (Received 11/23/2020)
  • Updated Mitigation Plan (Received 11/23/2020)


The team reviewed documents not received from Case Management Visits.
  • Proof of yearly 8 hour training for all Med Tecs for the last three years by end of day 11/24/2020
  • RO also requested proof of independent pharmacy consultant by end of day 11/24/2020
  • Staff screening logs for 11/20-11/22 for staff by end of day 11/24/2020

The team reviewed documents received and pending corrections from POC for previously identified citations 11/13/2020. RO requested revision and resubmission to include the following:
  • 87468.19- Addresses Joseph but who will take on the role when Joseph contract is gone
  • 87405- Licensee’s administrator qualifications training are to include Infection Prevention Modules for RCFE, DSS vendored administrator courses, and Dementia Hand in Hand training enrollment by 11/30/2020. TM requested extension for proof of completion of taking courses, deadline to be determined.
  • 87555- Specify servesafe or another type of training that new staff will complete.
  • LPM will look into what is specific to a 80 bed facility and provide technical assistance to Maria to update.
  • Update Plan of Operation to reflect staff roles and responsibilities due by 11/30/2020
  • Job Descriptions of Personnel- overall all administrator but RO is requesting clarification who is taking overall responsibility for what area due by 11/30/2020.

Continued on 809 C.
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SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: HOPKINS MANOR PACIFIC CORPORATION
FACILITY NUMBER: 415600927
VISIT DATE: 11/24/2020
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The team did not discuss items due from the Non Compliance Conference. Maria and Ricardo are to review documents and identify documents pending to the RO. LPA emailed the 9111 and 809 again to the facility.

An exit interview was conducted with Maria. A a copy of this report was provided to Maria via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Maria is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/24/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3