415600927-12-3-2020-14-AS-ABOE-BVY282-20201203160936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/03/2020
Date Signed: 12/03/2020 04:11:23 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: 25	DATE:	12/03/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricard Aban		TIME COMPLETED:	03:00 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 3, 2020, Licensing 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 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. Surveillance testing completed on Monday and all negative results reported today. The team discussed the Line List watch residents. Resident one no changes in condition and wants to come back the facility. Helen requested the facility communicate with hospital daily. Resident two no changes in condition. Resident three had a nurse tele visit yesterday no signs and symptoms of infection and potentially will be taken off hospice care. Resident four is doing well, up, and walking NP visit is scheduled today. Resident five drinking, eating and Nurse reported stable, improved appetite. The team toured the facility. Observed new entry with sanitizer and PPE upon entry. The front door is unlocked visitors and staff entry now through this one point of entry Ricardo stated Travis will be installing a doorbell today. Camera installed and video is currently linked to office, but once the new phone system is in place there will be a monitor in the ED office or reception area. The ED office is being set up with furniture in place. Ricardo stated he spoke to the phone company, they have limited staff, and the upgrade installation will commence once the technician COVID results are available, he tested yesterday. Residents were observed in the activity room wearing a masks. LPA provided TA to always ensure social distancing in that area. Staff screening a visitor logs were in place at the reception area. The designated screener was sitting at the table, it was observed a staff coming on to shift came into the facility and the screener took her temperature and recorded the screening responses. LPA requested to observe 4 staff screening entries, two were signed off by a NOC shift staff not designated on the LIC 500 as a screener. Ricardo stated they will make adjustments to include the designated NOC shift screener.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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: 12/03/2020

NARRATIVE

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The team requested to observe a staff don and doff PPE as if they were going into an isolation room. The staff practiced hand hygiene, then gloved, gowned, and gloved. She did not change into an N95 and put on a shield upon request. During Doffing she removed gloves, gown, and gloves. Helen requested Ricardo’s feedback and identified the sequence and the use of double gloves was not in line with CDC guidance. Helen recommended that included in the IP job duties would be to provide training to staff and spot check one or two staff daily to ensure proper donning and doffing practices were followed at all times. She recommended he train the other manager so they would be able to assist in the return demonstrations as well. LPA Boothe sent Ricardo the CDC videos for donning, doffing, and N95 seal check.

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

In response to the NNC Conference Letter from Ricardo.

1. Comply with COVID-19 Mitigation Plan at all times.
· Final Mitigation Plan received, monitor compliance on daily calls, televists, and health and safety checks.
2. Ensure completion of all staff training and assign administrator responsibility to spot check for understanding.
· Have not received proof of training's and signed off job duties, Maria requested extension to 12/7/2020.
3. Update Plan of Operation reflecting roles and responsibilities
· Plan of Operation updates not received
4. Hire an Executive Director by December 1, 2020
· Completed
5. Develop and maintain compliance with Staffing Plan and update of caregiver ratio dependent on reappraisal of the residents needs and service plans. Include a plan of action for what to do if a staff calls out including offering overtime and contracting contracted staffing agencies that can provide immediate staffing resources.
· Proof of signed contract and reappraisal of resident needs and services plans due to the RO.
6. Provide LIC 500 to the Regional Office and updated LIC 500 once ED is hired.
· Updated as of 12/3/2020 with roles, Designated screener 1, 2, 3 due to RO, Maria requested an extension to 12/7/2020.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

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: 12/03/2020

NARRATIVE

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7. Develop and maintain compliance with a Medication Management Plan that includes contract with the new pharmacy, renovate medication room, consolidate records to one binder, and assign administrator responsibility to audit daily.
· Maria requested extension to 12/7/2020 to provide auditing forms and proof of auditing practices.
· Copy of resident hourly logs will be send to the RO by end of day 12/3/2020.
8. The facility has a contract with Community Care Options a DSS certified vendor where administrators are enrolled to courses vital to enhancement of knowledge and understanding of Title 22. This vendor provides training courses and updates even RCFE initial administration certificate and renewal.
· 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.
· A stand up meeting is conducted every beginning of the shift and a separate Management Committee Meeting is done among the managers and the Licensee where the new ED is taking the lead on a daily basis.
· Maria stated stand up meeting today was conducted by her. She discussed roles of Med manager and the new med cart. She requested staff need to learn Identified roles with patient care manager, lead staff, and caregivers. They need to sign their assigned duties. Who and When to report and documenting expectations. POC for soap not available and caregivers are ok with provided hand washing assistance to all residents. Travis stated he wants to amend the Plan of Operation to include no soap will be available and all residents will be provided assistance with hand washing.
· Managers including the ED is taking turns to monitor every hour making sure that the hourly log is updated every in each floor. Requested resident records be sent by end of day 12/3/2020 to RO, unable to see on TA.

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: 12/03/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020

LIC809 (FAS) - (06/04)

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