415600927-12-18-2020-14-AS-ABOE-BWEUXB-20201218145804

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/18/2020
Date Signed: 12/18/2020 02:58:31 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:	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:	12/18/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban, Martha Estalano and Susan Ladeza.		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 18, 2020, Licensing Program Manager (LPM) Liza King and Licensing Program Analyst (LPA) Ashley Boothe conducted an unannounced case management visit via Microsoft Teams at 1pm. The team met with Infection Preventionist Ricardo Aban, and Executive Director Martha Estalano and Office Manager Susan Ladeza. Line list resident one will possibly be released on Wednesday, Martha stated she will follow up on Monday and complete a resident reappraisal prior to Wednesday. Line List was not submitted to the RO, Martha stated it will be send this afternoon. LPA observed residents in dining area and activity room wearing masks and maintaining social distancing. Screening logs for staff were observed to be completed and designated screener is signing off consistently as designated on the LIC500. Kitchen observed to be clean and stocked with food. Stickers were observed to include preparation and expiration dates. Lasagna was served being prepared for dinner. Sharps were observed locked and properly stored. The kitchen hand washing sink was stocked with soap, paper towels, and hand washing sign. Rooms 14, 36, and 28 were observed to have trash cans with a lid and laundry baskets lined. Restrooms observed were all stocked with soap, paper towels, and hand washing signs. LPM requested all resident hourly logs be moved into the inside of resident rooms so no personal information is accessible to visitors or residents. LPM recommended putting a clipboard on the inside of the door. PPE supplies stocked at sanitization station, backup storage in room 31. Ample supplies of PPE, Travis is taking inventory and collaborates with Ricardo to make sure there is enough supply. LPA will send burn rate calculator resources via email. Laundry area observed. Zep in the apron pocket of staff, staff was not able to state the sit time or name of the product without assistance. LPA recommended more training for disinfection during the stand up meetings. Dry food storage was observed, hand soap stored underneath canned foods. Other food items stored on the floor. Ricardo will stated they will go through the area to make sure all food storage areas are properly maintained. A new chef has been hired but delayed start due to COVID exposure and will start after a negative COVID test, updated LIC500 will need to be sent. Exit door alarm not sounding on floor two, Ricado stated maintenance work being done today. Work order will be sent to RO for the alarm company by end of day 12/18/2020. 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: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

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: 12/18/2020

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Continued from 809.

In response to the NCC Compliance Plan items pending:

Dementia Care Plan received will be reviewed by the RO by Wednesday 12/23/2020.

Residents’ reappraisals of needs and services plans received will be reviewed by the RO by Wednesday 12/23/2020.

Information for all PRN’s and on hand supply was compiled by Medical Technician and sent to the new pharmacy on 12/17/2020. January 2021 MAR’s will be printed for all medications for all residents.

LPA observed new written log for stand up meetings created on 12/17/2020. Stand up meeting on 12/18/2020 topics covered: 1) Travis is concerned with testing of staff and residents retesting who were positive 90 days ago during the mass testing scheduled for 12/20/2020, LHD has been contacted. 2) Resident specific needs and medical appointments scheduled. 3) Completion of resident hourly logs. 4) Mitigation plan and disinfection practices. 5) Reminded staff to report low inventory supplies to Ricardo

No deficiencies were observed during today’s visit. 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: 12/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2020

LIC809 (FAS) - (06/04)

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