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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/23/2020
Date Signed: 11/23/2020 04:38:44 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:
11/23/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Travis WycoffTIME COMPLETED:
11:30 AM
NARRATIVE
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On November 23, 2020 Licensing Program Analyst LPA Ashley Boothe conducted an unannounced health and safety case management visit at 9:00am with Licensee /Administrator Travis Wykoff.

LPA followed signs to a designated entry point on the second floor of the facility where COVID precaution and visitor signs were posted on the front door. LPA rang the doorbell and were allowed entry to the facility staff who screened LPA for temperature and symptoms of COVID-19. LPA requested to meet with Travis stated the purpose of the visit.

LPA observed staff wearing masks and residents wearing masks practicing social distancing. LPA observed clutter has been removed, hand washing signs, signs and symptoms, and PPE guidance signs were posted throughout the facility. LPA observed 5 PPE stations all stocked with PPEs. Travis stated he was ordering plastic PPE carts from Home Depot.

LPA toured the third floor and provided technical assistance to Travis on options for creating an isolation quarters between rooms 16-19. Travis stated he would send the updated facility map with isolation areas demarked as well as resident rooms to LPA by the end of day 11/23/2020.

LPA toured dining and activity rooms and Travis discussed plans for renovating the new ED’s office and reception area, LPA provided technical assistance to support the option which would allow the receptionist a direct line of cite to the activity room.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
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 4
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: 11/23/2020
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Continued from 809.

LPA toured the kitchen, no expired or improperly store foods were observed and it was clean and organized. LPA provided technical assistance to post a handwashing sign at the kitchen sink. LPA interviewed the new chef who stated she was working on providing training to kitchen staff for taking refrigeration temperatures and taking food safety training courses. LPA toured the first floor LPA observed one expired food product in the back of dry goods storage and provided technical assistance and chef stated she was in the middle of going through and organizing the area. LPA observed ample supplies of perishable and non perishable food. LPA observed food preparation procedures are in compliance with Title 22 regulation at the time. All other areas in the laundry, break room, resident’s rooms and restrooms have been maintained and chemical storage was observed to be locked and in compliance with Title 22 regulations at the time.

LPA observed deficiencies in the Medications Room. LPA reviewed documents and observed PRN Medication Log for resident one where PRN’s administered by overnight caregiver two times and PRN Medication Log for resident two where PRN’s administered by overnight caregiver three times. LPA observed PRN Medication Log for resident three PRN’s given to resident three times where indicated on Physician Authorization for Over the Counter Medications resident can not take the medication. LPA requested Medical Training logs for the past three years for staff be sent by end of day 11/23/2020.

LPA and Travis discussed resident four and his ability to return to the facility to pick up belongings, reviewed LIC 602 and provided technical assistance to contact Genie for guidance on if resident would be allowed into the facility at this time under LHD guidance. Resident is unable to administer his own medications, LPA provided technical assistance to contact the case manager to coordinate pick up.

Travis stated the phone system appointment had been cancelled due to the installer coming down with a fever, no estimated time of rescheduling as of today.

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

DATE: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC809 (FAS) - (06/04)
Page: 2 of 4
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: 11/23/2020
NARRATIVE
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LPA and Travis observed the temporary elevator inspection as dated 2/2020. Travis stated he would follow up and provide proof of contact and notify LPA of current state of inspections due to COVID-19 precautionary measures.

LPA and Travis reviewed staff screening logs. LPA interviewed staff two who stated the noc shift staff did screen her on her way in. LPA and Travis reviewed documents and observed staff screening for 11/23/2020. Some staff have initials that another staff screened them but at this time it is unclear if staff practices self screening or is following the Mitigation Plan with a dedicated staff member to screen staff and visitors. LPA requested staff screening logs for 11/20-11/22 for staff be sent by end of day 11/23/2020.

LPA and Travis reviewed the Suspension of Admission Letter dated 11/23/2020. LPA provided two copies to Travis, one for personal review and one to post in the facility as instructed on the document.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Travis. A a copy of this report was provided to Travis via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Travis 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: 11/23/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2020
LIC809 (FAS) - (06/04)
Page: 3 of 4
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/23/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/24/2020
Section Cited

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80075(b)(5)(c) Health Related Services. The PRN medication record shall include the date and time the PRN prescription and nonprescription medication was taken, the dosage taken, and the client's response.
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This requirement is not met as evidenced by: LPA and S2 observed PRN Medication Log Review where two residents received assistance with PRN's by caregiver staff and one resident was administered PRN against physicians orders on Physicians Authorization for over the counter Medications Log which poses an immediate risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2020
LIC809 (FAS) - (06/04)
Page: 4 of 4