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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/30/2020
Date Signed: 11/30/2020 05:02:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, 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:
11/30/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Susan Ladeza and Martha EstalanoTIME COMPLETED:
02:00 PM
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On November 30, 2020, Regional Manager Krystal Moore, Licensing Program Manager (LPM) Liza King, Program Analyst (LPA) Ashley Boothe, and DSS Nurse Consult Helen Shi conducted an announced case management visit via Microsoft Teams at 1pm. The team met with Martha Estalano Administrator, Susan Ladeza Administrator, and Temporary Manager Maria Cantoria

The team discussed the Line List watch residents. The team confirmed Resident one has picked up all medications with a Nurse Practitioner, RO requested copy of pick up letter 11/25/2020. Other belongings are pending pick up. LPA Boothe requested change made to line list to reflect accurate details of pick up. RO requested rescinded eviction notices for the resident. Resident two has refused repositioning, when that happens Helen recommended asking why and then try to move her to her wheel chair. Resident three is eating chocolate ensure and doing well, no changes, walking staff exercise, nuts and walking. Family is coming to do a door visit. Resident four is walking exercise from time to time, follow up on new shoes to accommodate bunions today. Resident five started having outbursts running out of her room and screaming. Dr. Martin, ordered increase of medications and ordered sending her to San Mateo Medical Center, resident was sent out at 1pm today. Continuous 1:1 care is not enough during the outbursts. Please update RO with doctor's notes.

RO received requested documents as of 11/30/2020:
  • Proof of yearly 8 hour training for all Med Tecs for the last three years by end of day 11/24/2020
  • Job Descriptions and designated staff assignments for Licensee/ Owner, Office Manager, Business Office Manager/Public Relations, ED/Administrator, Resident Care Manager, and Chief Financial Officer/HR.
  • Job Descriptions for Lead Staff, Licensee and Caregivers. (Received 11/30/2020)
  • Rescinded Eviction Notice for Resident one. (Received 11/30/2020)
  • RO also requested proof of independent pharmacy consultant agreement (Received on 11/25/2020)
  • LIC 500 with schedule (Received 11/23/2020)
  • Facility sketch (Received 11/23/2020)
  • Updated Mitigation Plan (Received 11/23/2020)
  • Staff screening logs for 11/20-11/22 for staff by end of day 11/24/2020
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020
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: 11/30/2020
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The team reviewed documents not received from Case Management Visits.
  • 87468.19- Addresses Joseph but who will take on the role when Joseph
  • Mitigation Plan addendum by 12/2/2020 identifying who will take Joseph is gone.

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:
  • 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. requested an extension to 12/2/2020.
  • 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. requested an extension to 12/2/2020.
  • 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 requested an extension to 12/2/2020.

  • Requested another copy of NCC Plan.
  • Will check updated phone systems, Ricardo on elevator maintenance.



An exit interview was conducted with Susan and Martha. A a copy of this report was provided to Susan and Martha via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Susan and Martha 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: 11/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2020
LIC809 (FAS) - (06/04)
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