415600927-11-24-2020-14-AS-ABOE-BVNVXS-20201124155001

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/23/2020
Date Signed: 11/24/2020 03:51:10 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 CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	WYCKOFF, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 25	DATE:	11/23/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Travis Wycoff		TIME COMPLETED:	03:00 PM

NARRATIVE

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On November 23, 2020, Regional Manager Krystall Moore, Licensing Program Manager (LPM) Liza King, Program Analyst (LPA) Ashley Boothe, and Department of Public Health HEFN Rebekah Bird-Wohlgemuth conducted an announced case management visit via Microsoft Teams at 1pm. The team met with Travis Wyckoff Licensee/Administrator and Maria Cantoria Temporary Manager.

During the TA, the following was confirmed, current census today 25; 20 positives of which 20 have cleared and 5 that are negative.

Staff testing was planned for 2pm and Executive Director Ricardo Aban joined at that time he came in for surveillance testing.

Line List update

Travis confirmed resident one has passed on 11/21/2020 and Death Report was sent to the San Bruno office with in the 24 hour report requirement. LPA Boothe reviewed fax confirmation receipts during the health and safety visit. The RO has requested all SIR’s and Death Reports be sent to LPM King, LPA Boothe and the Sacramento South Office while we are overseeing the facility. Travis confirmed the fax number and stated he will inform staff of this change once again.

The RO requested an Infection Preventionist be hired or identified among current staff to be trained and certified to work on site 40 hours per week. The IP role cannot be a dual role.

LPA Boothe provided a recap of the health and safety visit including deficiencies cited, technical assistance provided for the areas observed the physical plant, COVID signs, potential isolation zone, PPE stations, food preparations, chemicals and toxins stored, staff and residents wearing a mask, medication management, and staff screening processes.

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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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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Continued from 809.

Travis updated the team on resident will be allowed in the facility as a visitor per LHD’s guidelines but will be encouraged to allow facility staff to pack up his belongings, so he does not need to come into the facility. Resident has medications until Wednesday and need to request case management team to pick up medications or show proof of an updated LIC602 stating resident is allowed to administer his medications without assistance.

Travis updated team on the status of the phone system installation postponed due to installer coming down with a fever. COVID negative test will be required prior to entry to the facility. Staffing plans were discussed and Travis stated he plans to hire another Administrator and two additional caregivers. Previously he stated he was interviewing but no hiring decisions have been made at this time.

Staff screening process in the Mitigation Plan states:

There will be always a designated staff member assigned to do the screening of staff, residents, and visitors, who must strictly comply with public health guidelines and recommendations. Based on the documentation observed it appears that staff are self-screening. Travis stated the practice is being followed and staff are not self-screening. LPA restated the technical assistance provided on the health and safety visit. LPM stated it was that the documentation leads room for questioning of the practice and there is inconsistency in how staff documenting if they self screen or screen each other.

Maria stated that up to the point that the COVID outbreak started he was hands off to the operations of the facility. He is trying to catch up but there have been instances with communication and follow through. At this time Maria has requested all emails be sent to her as well so she can ensure timeliness of sending documentation to the RO.

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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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 C

Due Dates for items to be submitted to the RO by end of day 11/23/2020 were reviewed and included the following:

· LIC 500 with schedule

· Facility sketch

· Proof of yearly 8 hour training for all Med Tecs for the last three years

· RO also requested proof of independent pharmacy consultant reviews

· Staff screening logs for 11/20-11/22 for staff

· Updated Mitigation Plan

· POC for previously identified citations 11/13/2020

· Update Plan of Operation to reflect staff roles and responsibilities

· Job Descriptions of Personnel

All 809 reports of case management visits need to be signed and returned to the RO as soon as possible, deadline not solidified at the time.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (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)

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