415600927-12-2-2020-14-AS-ABOE-BVX3FE-20201202171236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/02/2020
Date Signed: 12/02/2020 05:13:10 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:	WYCKOFF, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 24	DATE:	12/02/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	02:00 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 2, 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 Ricardo Aban Executive Director, Martha Estalano Administrator, 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 was admitted to the hospital, needs to be revaluated and be stable before coming back to the facility. Team observed weight record of a 26 lb weight gain from August 1, 2020. Documentation requested that doctor was notified for weight gain for weight gain notifications to PCP by end of day 12/2/2020. Helen requested the facility communicate with hospital daily. Resident two nurse visit on 12/2/20 will not downgraded wound status but noted healing and continue to keep her legs elevated. Resident three had a nurse visit today and it was noted there was no longer foul smelling urine, no appetite changes, no signs and symptoms of infection and they will continue to monitor urine. Resident four is doing well, up, and walking and NP visit is scheduled today. Resident five is drinking, eating and Nurse reported stable, improved appetite. Refused to be weighed but not refusing repositioning. continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020

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: 12/02/2020

NARRATIVE

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The team discussed items received and due to the RO. LIC 500 was submitted to the RO on 12/1/2020. Staff screening was designated to staff Monday- Friday. RO requested an updated LIC500 to include designated screener including weekends and identifying the IP by 12/2/2020. Staff training for the IP role does not have the medical background to understand the needs of the role. Ricardo stated he would like to send a plan proposing a dual role to the RO by 12/2/2020 for RM review. Ricardo sent pictures of the soap dispenser installed in room 37, stated Travis ordered more 8 but caregivers help all residents with hand washing and all residents have soap secured in locked cabinets in the restrooms. The team discussed the resident’s reappraisals for whether or not they can have access to soap in their rooms. Residents’ reappraisals need to be completed in accordance with ensuring the staffing plan is in place to accommodate care plans. Due to the RO by 12/2/2020 as previously communicated.

The team reviewed documents not received from Case Management Visits.

LIC 500 by end of day 12/2/2020
Mitigation Plan addendum by end of day 12/2/2020 identifying who will take Joseph is gone.
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. POC extension request o 12/15/2020 sent to the RO by 12/2/2020

The team reviewed documents received and pending corrections from POC for previously identified citations 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. Emailed list of courses to RO on 11/30/2020 RO requested proof of enrollment as the picture sent on 12/1/2020 was unreadable.
· TM requested extension for proof of completion of taking courses, deadline to be determined. Emailed Course list on 11/30/2020, enrollment not confirmed.
· 87555- Specify servesafe or another type of training that new staff will complete. Requested an extension to 12/2/2020. RO requested proof of enrollment as the picture sent on 12/1/2020 was the course page not the certificate.
· Update Plan of Operation to reflect staff roles and responsibilities due by 11/30/2020 Requested an extension to 12/2/2020.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020

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: 12/02/2020

NARRATIVE

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RO received requested documents as of 12/2/2020:

Proof of IP certification – Ricardo Aban
Medication audits by Maria
Pictures of sign and soap dispensers in restrooms observed missing on 12/1/2020
Staff screening logs with staff sign off to show staff are not self screening, designated

· 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

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: 12/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2020

LIC809 (FAS) - (06/04)

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