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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/09/2020
Date Signed: 12/09/2020 04:33:41 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: 25DATE:
12/09/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Martha EstalanoTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Ashley Boothe made an announced case management televisit on 12/9/2020.

LPA Ashley Boothe received an incident report from Executive Director Martha Estalano sent to the Regional Office (RO) on 12/5/2020 documenting the suspected staff to resident abuse reported via text message to Licensee Rozz Wycoff on 11/30/2020 by terminated Staff two (S2). On the 12/7/2020 daily call, LPA Boothe requested a SOC341 and a picture of the text message S2 sent to Licensee be sent to the RO. LPA Boothe reviewed the SIR, SOC341 and text message. An interview was scheduled with LPA Escobar and Resident one (R1) via Facetime at 1pm on 12/8/2020 for LPA to conduct the interview in Spanish. During the interview it was determined that S1 did not physically harm R1 as there were no signs of injury and R1 did not recall an incident, and stated she has no complaints and stated no area of pain in her body. Throughout the interview R1 was not being coached or prompted what to say. R1 was observed alert and stated everyone treats her good.

Exit interview was conducted with Martha. Copy of the report sent to Martha via e-mail with a "read receipt" to verify the LIC 809 was received. Martha is to print out the report, sign it, and fax a signed copy to LPA at 916-263-4744.
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)
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