415600927-12-8-2020-14-AS-ABOE-BW4W5G-20201208155908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/08/2020
Date Signed: 12/08/2020 03:59:37 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: 24	DATE:	12/08/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo 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 8, 2020, Licensing Program Manager (LPM) Liza King, 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 Executive Director Ricardo Aban, Martha Estalano, Susan Ladeza and Maria Cantoria Temporary Manager. Census 24 on site with resident one in the hospital. The team observed the front entry including the locked front door, working door bell, no visitors allowed, door visit protocols, instructions for entry, mask required signs. Sanitizer available outside and immediately upon entry. Ricardo stated disinfect the handrail every shift three times daily and at night doing a deep cleaning the handrail. The team observed receptionist screen Licensee Rozz Wycoff by taking temperature and practicing hand hygiene outside and asking and documenting signs and symptoms and then Rozz signing off. Helen recommended to add screening questions to include if there has been exposure to someone with to COVID or traveled domestically or internationally in the past 14 day. Helen recommended to contact Home Health Agencies and develop a plan for Nurses who travel from other COVID positive facilities wearing new full PPE, including new PPE upon entry. Martha provided a demonstration of donning PPE including, hand hygiene, gown, N95 including deal check, face shield, hand hygiene, gloves, and hand hygiene. Martha provided a demonstration of doffing PPR including removal of gown and gloves at the same time, discarding gown and gloce, hand hygiene, removal of face shield, removal and discarding of N95 and hand hygiene. Helen asked Ricardo for areas of improvement, he addressed opportunities with the N95 and gown doffing. Helen stated she to ensure the sleeves should be inside the gloves, not to use hand sanitizer after donning gloves, and doffing the PPE and discarding inside the isolation room. Ricardo stated he and the IP will complete return demonstrations including managers and staff today. Helen recommended reviewing the video on a weekly basis. Helen recommended Review of the Mitigation Plan. Ricardo The phone system upgrade installer received negative COVID, work started today on upgrading the phone and wifi systems.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020

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: 12/08/2020

NARRATIVE

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The team requested to observe the planned isolation rooms 16-19. Room 19 is not move in ready for isolation, with personal items still in place. Ricardo stated he has seen it in other facilities and will do it himself, the area could be ready 12/10/2020. Travis was going to order partisan and PPE carts, Ricardo stated he will do it himself. Helen provided TA that if someone starts to develop symptoms they need to be immediately be quarantined. LPM recommended to review the mitigation plan to ensure all items in the mitigation plan are implemented. The team will review by the next TA on Tuesday at 1pm or sooner at Ricardo’s request. New admissions can not come into the facility unless this area is prepared.

The team discussed the Line List watch residents. Martha is now working on the line list. Resident one is stable at Good Samaritan and they are working on the medications, responsible parties notified. Resident two no changes. Resident three no changes, LPA requested update on line list. Resident three no changes. Resident four no changes. Resident five no changes.
Items Requested to the RO.
· Provide LIC 500 as 12/9/2020
· Resident Reappraisals of need and care plans
· A plan for when Ricardo will host the meetings and ensure communication among staff by 12/8/2020
· Preparation of Isolation Area
· Susan’s job description highlighted with updates
Items submitted to the RO fore review by end of day Wednesday 12/16/2020.
· Provide LIC 500 with Designated screener 1, 2, 3
· Updated Job description’s
· Medication Management Audit forms and proof of auditing practices
· Plan of Operations and Dementia Plan addendums
· Staffing Agency Contract
· Proof of Enrollment for Travis in IP and Dementia training 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: 12/08/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2020

LIC809 (FAS) - (06/04)

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