<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/09/2020
Date Signed: 12/09/2020 04:33:07 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:ABAN, RICARDOFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 24DATE:
12/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Martha EstalanoTIME COMPLETED:
02:45 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 9, 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 2pm. The team met with Infection Preventionist Ricardo Aban, Executive Director Martha Estalano, and Office Manager Susan Ladeza, Census 24 on site with resident one in the hospital.

The team discussed the Line List watch residents. Resident one facility is calling daily to check on her and will follow up with reappraisal when discharge plans are in place. No changes reported for the remainder of residents .
LPA stated an updated copy of the new licensee will be mailed tomorrow, no changes in the facility number.
Ricardo stated the phone system upgrade is a work in progress, installer was not on site today.

LPA recommended review of Mitigation Plan to ensure plan is implemented to include but not limited to the use of physical barriers, color coded zone signs, hand washing signs, stocked PPE stations, PPE guidance, staff screening area, staff break room, staff restroom. All rooms will be prepared according to the Mitigation Plan. Helen recommended developing a plan on how to fill rooms and what to do in multiple situations including positive residents and new admissions. Ricardo asked about quarantine procedures and LPA will provide link to CCLD website, PIN's and how to sign up for PIN's.

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 12/09/2020
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
26
27
28
29
30
31
32
Items Requested to the RO.
Resident Reappraisals of need and care plans for all residents by 12/18/2020
Executive Director Job Duty Statement
Signed infection Preventionist Job Duty Statement

RO will review previously submitted items by Wednesday 12/16/2020.

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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2