415600927-12-4-2020-14-AS-ABOE-BVZ33A-20201204165314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/04/2020
Date Signed: 12/04/2020 04:54:55 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:	ABAN, RICARDO		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS:	DATE:	12/04/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	04:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On December 4, 2020, Licensing Program Analyst (LPA) Ashley Boothe and DSS Nurse Consult Helen Shi conducted an announced case management visit via Microsoft Teams at 2 pm. The team met with Ricardo Aban Executive Director, Martha Estalano Administrator, and Susan Ladeza Administrator and temporary Manager Maria Cantoria Census 24 on site with resident one in the hospital The team discussed the Line List watch residents. Resident one no changes in condition. Resident two repositioning every two hours and moved to bed after lunch to relive pressure on her buttocks. Resident three potentially will be taken off hospice care, facility is to follow up with Hospice company to request discharge summary if she is moved off the critical list. Resident four is now spending time in the afternoons in the activity room reading, Helen requested a sign be posted in room to ask for help. Facility states she needs additional care but not to the level of 1:1 care at this time. Resident no change in condition. Helen recommended to look at history of falls and skin breakdowns as the team reappraises the resident care plans.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020

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: 12/04/2020

NARRATIVE

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The RO received the Proposal for a dual ED and IP role on 12/3/2020, RO will review.

The Team then reviewed action items due in response to the NCC Conference Letter from Ricardo as outlines on 12/3/2020 report.

· Have not received proof of trainings and signed off job duties, Maria requested extension to 12/7/2020.
· Plan of Operation updates not received
· Provide LIC 500with Designated screener 1, 2, 3 due to RO, Maria requested an extension to 12/7/2020.
· Medication Management Audit forms and proof of auditing practices Maria requested extension to 12/7/2020
· Proof of Enrollment for Travis in IP and Dementia training due to the RO. Progress of CCO training due to the RO. Proof of registration in CCO classes for Travis provided to the RO showing a due date of completion February 2021.

An exit interview was conducted with Ricardo. A copy of this report was provided to Ricardo via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Ricardo 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: 12/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020

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: 12/04/2020

NARRATIVE

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The team discussed the hourly resident logs and reviewed two provided to the RO on 12/3/2020. Staff are signing off hourly documenting diaper changes, fluid and food intake but not documenting repositioning, exercise or massage of residents. Maria requested ED and administrators follow up with caregivers to document more details. LPA requested an additional column for ED or administrator sign off. Staff and visitor screening practices included a discussion of the process including the designated screen also fills out the logs and ensure legibility in documentation printing, currently they logs have some documentation that is hard to read. Ricardo stated they have polished the screening process to include the designated screener answers the door, takes the temperature before entering the door, directs to sanitize and change PPE upon arrival and discard in trash can with a lid in that area, instructs to stand on a 6 ft mark on the floor, interviews and then will start to document. Ricardo stated Travis has not installed the doorbell yet. Ricardo stated PPE training is being conducted, videos will be watched by all staff and sign off will be completed by 12/7/2020. Resident Care Manager and Travis conducted the stand up meeting today and discussed residents care needs. Ricardo stated he will start conducting a Management Committee Meeting at 2pm since he is not in the facility until 9am after the stand up meeting occurs. The NNC compliance states he will conduct a daily stand up and Management Committee Meeting will occur where he takes the lead. The RO requested a plan for when he will host the meetings and ensure communication among staff by 12/7/2020. Ricardo stated he and Maria will review, amend and resubmit job descriptions will be rewritten and submitted and requested an extension and will incorporate in the addendum. Ricardo stated Travis interviewed the new chef who shadowed in the kitchen for 4 hours yesterday and the RO has requested a copy of the negative COVID test as outlined in section IV of the mitigation plan be submitted to the RO by 12/7/2020. The Phone system vendor has not furnished a negative COVID test for the installer. Ricardo stated Travis is looking into breaking the contract and finding someone else. The RO requests proof of installation scheduled by 12/7/2020. Maria requested Ricardo review resident contracts to look to request two residents provide personal cell phones so they do not over use the facility lines.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2020

LIC809 (FAS) - (06/04)

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