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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415600927
Report Date:
10/03/2020
Date Signed:
10/07/2020 02:52:29 PM
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
FACILITY NAME:
HOPKINS MANOR PACIFIC CORPORATION
FACILITY NUMBER:
415600927
ADMINISTRATOR:
WYCKOFF, TRAVIS
FACILITY TYPE:
740
ADDRESS:
1235 HOPKINS AVENUE
TELEPHONE:
(415) 806-4069
CITY:
REDWOOD CITY
STATE:
CA
ZIP CODE:
94062
CAPACITY:
88
CENSUS:
35
DATE:
10/03/2020
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
09:00 AM
MET WITH:
Travis Wyckoff
TIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit regarding the transferring of COVID positive residents. LPA met with the licensee Travis Wyckoff at the front of the facility. LPA also met with San Mateo Department of Health leads and AMR lead coordinator. LPA discussed purpose of today's visit with licensee and other leads present.
LPA observed the transfer of residents from the facility to be assessed in local hospitals. During time on site LPA observed the transfer of two residents from facility to AMR ambulance for transfer to be assessed at local hospital. LPA collected resident transfer information and documentation for each resident transferred. LPA discussed staffing levels and the continuing plans for the facility to ensure residents are being cared for while in facility. LPA discussed the documentation and guidelines that LPA sent to the licensee via email on 10/02/2020 regarding COVID along with required postings and CHHS guidelines that need to be put in place. Licensee acknowledged the receipt of those items. Food supplies are in place according licensee. Breakfast is made and served on site. Lunch and dinner is catered in and according to licensee there have been no issues or delays regarding catering of food.
At end of on site visit LPA was relieved by another LPA and briefed on current situation and requests from facility by program office.
No deficiencies cited during todays visit. Report discussed with licensee. A copy of this report will be sent to licensee via email.
SUPERVISOR'S NAME:
Julio Montes
TELEPHONE:
(650) 272-7906
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
10/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/03/2020
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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