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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/07/2020
Date Signed: 12/08/2020 08:01:33 AM

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: DATE:
12/07/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Martha Estalano and Susan LadezaTIME COMPLETED:
03:00 PM
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On December 7, 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 2 pm. The team met with Martha Estalano, Susan Ladeza and Temporary Manager Maria Cantoria.

Census 24 on site with resident one in the hospital

The team discussed the Line List watch residents.

Resident one has transferred to Good Samaritan Hospital Friday night. Resident two no changes. Resident three has three new scratches on her feet and Helen recommended padding the bed rail to avoid rubbing. Nurse instructed do not turn to left side until her wounds are healed. Resident three no changes and will be evaluated next month to be taken off hospice. Resident four no changes. Resident five positive changes in condition and ate solid foods.

LPA requested SOC341 for resident incident.

Martha stated she received a call from Travis, Maria, and Ricardo on Sunday to ask is she would take over the IP job duties and she accepted. The RO received the Proposal for a dual ED and IP role on 12/3/2020. Review with RO.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
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: 12/07/2020
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Items pending to the RO.

· Proof of trainings and signed off job duties
· Plan of Operation updates
· Proof of auditing practices for medication manage
· Updated Job description for Susan including medication management audits daily
· A plan for when Ricardo will host the management meetings and ensure communication among staff by 12/7/2020
· Update on the Phone system upgrade


Items submitted to the RO fore review
· Provide LIC 500 with Designated screener 1, 2, 3
· Medication Management Audit forms
· Proof of Enrollment for Travis in IP and Dementia training Progress of CCO training. 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 Martha on 12/8/2020. A copy of this report was provided to Martha via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Martha 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: 12/08/2020
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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