415600927-12-14-2020-14-AS-ABOE-BWAR8G-20201214114756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/14/2020
Date Signed: 12/14/2020 11:48:27 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 CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	ABAN, RICARDO		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 24	DATE:	12/14/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Martha Estalano, Ricardo Aban		TIME COMPLETED:	11:45 AM

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 14, 2020, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit via Microsoft Teams at 10am. The team met with Infection Preventionist Ricardo Aban, and Executive Director Martha Estalano. Census 24 on site with resident one in the hospital. The team toured the isolation area. Observed one staff with Zep in her pocket and a spray bottle with sit time instructions on it. At the exterior of the area was a PPE station included a plastic 3 drawer container, proper signage for COVID area zone displayed, and donning and doffing procedures. Observed inventory was last counted on 12/11/2020 and Ricardo stated he train staff for twice daily inventory in the am and noc shifts and audit the inventory to check on hand supplies and place orders. The team toured the hall leading to four isolation bedrooms with private restrooms including sanitizer in wall mounted fixtures. The bedrooms were set up to include all furniture, proper signage, and lined hampers. Room 4 the staff break area was observed with a table and a refrigerator for staff to use. The restrooms were stocked with soap, paper towels, hand washing signs and gloves were available outside each restroom door. All cabinets observed locked. Ricardo stated all rooms will be stocked with extra linens and incontinent supplies by the end of today. Ricardo stated all staff will enter clean through the single point of entry at the facility and then exit through the fire exit in the isolation area. Plastic barriers were in place and Travis has ordered bi-fold partisan room dividers. Room 5 and 6 can be used as overflow isolation if necessary. LPA recommended planning for a locked area to store cleaning chemicals in the red zone. 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: 12/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020

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: 12/14/2020

NARRATIVE

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continued from 809.

The team toured the second floor. Observed locked front door and mock screening of Ricardo by staff. LPA observed the visitor and three staff screening logs to be in compliance with the mitigation plan and now included travel and exposure screening questions. Ricardo stated the ED office renovation is almost complete and phone system upgrade is a work in progress. Five residents observed in the activity area maintaining social distancing and wearing masks unless eating. Kitchen was stocked with food, one item observed to not have an expiration date, LPA provided recommendation to put a sticker to show open and use by date. Staff training logs were observed for 12/4 and 12/7 including donning and doffing skills competency check and return demonstrations. LPA provided recommendation to follow the department previous recommendation to ask for return demonstrations daily. Observed working pull cords in two rooms sounding to the kitchen. Two systems are in place in the facility, Ricardo stated he will look into which are working. The elevator inspection has been paid, Ricardo stated he will follow up to schedule. PPE was available and sanitization stations were observed in the main hallway.

The team observed the first floor, one resident was sleeping, room not observed. Common restroom observed were stocked with soap, paper towels, and hand washing signs. All cabinets observed locked. Laundry room was observed to have soiled linens on the floor not in the soiled linen receptacle. Ricardo stated they were in the process of doing laundry, LPA provided recommendation to train staff to move linen directly from covered receptacle to the washer instead of to the floor. Common staff break area was observed to have chairs placed for social distancing and wipes available for use.

No deficiencies were observed during today’s visity. An exit interview was conducted with Martha. 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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2020

LIC809 (FAS) - (06/04)

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