415600927-12-1-2020-14-AS-ABOE-BVW2RZ-20201201163823

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/01/2020
Date Signed: 12/01/2020 04:39:21 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: 25	DATE:	12/01/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	04:00 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 1, 2020, Regional Manager Krystal Moore, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, and DSS Nurse Consult Helen Shi conducted an unannounced case management visit via Microsoft Teams at 1pm. The team met with Ricardo Aban Executive Director, Martha Estalano Administrator, Susan Ladeza Administrator, and Temporary Manager Maria Cantoria The team observed the entrance to the facility locked from the exterior, signs posted, PPE, and sanitization station. RO requested screening logs and visitor logs for four staff sent by end of day 12/1/2020. Ricardo stated there are designated persons administrators or Travis to conduct screening but anyone who is close by can screen visitors and staff. Helen recommended to designated staff to screen, as outlined in Mitigation Plan, and ensure they have the identified person come to the door rather than who is closest. RO requested designated schedule be sent to the RO by end of day 12/1/2020. Ricardo stated Travis and Rozz have been interviewing for receptionists. The team observed the start of the new office set up according to updated facility map. ED office is being cleared out and a table for the receptionist has been placed and PPE is available in that area. Signs have not been posted yet. Ricardo stated it should be completed by Thursday. The team observed the kitchen. The chef has been terminated and requested updated LIC 500 requested by end of day 12/1/2020. Travis interviewed a new chef who toured the facility and toured the kitchen. Ricardo stated he will train the cook and monitor previously cited kitchen citations including properly stored chemicals, expired foods, and improperly stored foods. Other food stored was observed and facility has ample food supply. 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: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

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: 12/01/2020

NARRATIVE

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The team observed the med room. Ricardo stated the new pharmacy provided training on forms and processes to med tecs on 11/25/2020. PRN logs are still listed separately in another binder. PRN and MAR sheets have not been moved to a central binder and will not consolidate until new pharmacy proce. Maria stated she is auditing them and their system is working because POC was stated to be in one binder, Maria has not used a documented form. RO requested POC extension to 12/15/2020 will need to be requested and proof of auditing sent to the RO by end of day 12/2/2020. Helen requested Ricardo ask the pharmacy to color code the Centrally Stored Medications, MAR and PRN’s for ease of the med tecs to follow. The team met the new IP who has been assigned training to be in newly designated role for when the temporary management contract ends.

Three resident rooms 16, 11, and 47 were observed. Two of the three rooms did not have hand soap available, one restroom was observed without a handwashing sign.

Residents and staff were observed to be maintaining social distancing and wearing masks in common areas and in their bedrooms.

Laundry was observed and chemicals were observed to be locked in two storage areas.

PPE station was observed and Helen suggested IP does daily rounds to ensure signs are posted, PPE is refilled, and spot check staff to make sure PPE is donned and doffed correctly

Ricardo stated he completed IP training and will send certificate to RO by end of day 12/1/2020. He has taken over the Line list. Travis spoke to elevator vendor and they are requesting payment in advance, invoice has been received. Provide proof of payment to RO by Friday.

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: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/01/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/11/2020 Section Cited	1 2 3 4 5 6 7	Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities: (3) All persons shall be protected against hazards within the facility through provision of the following: (B) Information and instruction regarding life protection and other appropriate subjects.
	8 9 10 11 12 13 14	This regulations was not met as evidenced by the facility failed to protected against hazards within the facility by providing information and instruction regarding life protection and other appropriate subjects. Based on observation the facility did not to post signage for proper handwashing and two of three residents did not have access to soap.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

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: 12/01/2020

NARRATIVE

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The team discussed the Line List watch residents. Resident one was admitted to the hospital, needs to be reevaluated and be stable before coming back to the facility. Observation of weight gain, not specified. Resident two has increase protein intake to promote wound healing, skin intact and healed not open, egs suspended and repositioning every two hours. Resident three has had symptoms starting on 11/24/2020 for foul smelling urine, follow up make sure hospice notes are documented on the line list. No changes for other residents.

RO received requested documents as of 12/1/2020:
· 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

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: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

LIC809 (FAS) - (06/04)

Page: 4 of 5

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: 12/01/2020

NARRATIVE

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Continued from 809 C.

The team reviewed documents not received from Case Management Visits.
· 87468.19- Addresses Joseph but who will take on the role when Joseph
· Mitigation Plan addendum by 12/2/2020 identifying who will take Joseph is gone.
· Updated LIC 500 requested by end of day 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
· 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. Emailed Chef was terminated on 11/30/2020
· Update Plan of Operation to reflect staff roles and responsibilities due by 11/30/2020 Requested an extension to 12/2/2020.

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: 12/01/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2020

LIC809 (FAS) - (06/04)

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