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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/24/2020
Date Signed: 12/24/2020 02:15:03 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 CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:ABAN, RICARDOFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 25DATE:
12/24/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Martha EstalanoTIME COMPLETED:
11:30 AM
NARRATIVE
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On December 24, 2020, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Microsoft Teams at 10am with Executive Director Martha Estalano.

Line list was reviewed, no changes noted. Resident reported fall on 12/19/2020, interviewed resident, no complaints of pain in the area. Red zone partitions are in the process of being put up, LPA and LPM observed a ladder and tools unsecured and unsupervised in the lounge on the third floor. Martha stated Travis was working on it this morning but Travis was observed to no be in the area. Observed exit door on the third floor without batteries, no alarms sounded, and Martha stated only the second floor was fixed this week, Travis still needs to put batteries in the other doors. Cords and two power strips for in room 7 were a trip hazard on the floor to the right of resident’s bed, staff moved them at LPM’s request. Observed hourly logs for four residents on the third and second floors filled out for all residents in room 40, 7, and 6 and 36. Residents care was noted on the hourly logs according to the line list care plans and Staff one (S1) was able to speak to resident’s care needs when interviewed. Martha stated she is auditing medications every day, observed records completed from 12/17/2020 to current. Staff two (S2) stated Pharmacy will deliver MARs for 1/1/2021 next week. Medical technician stated he has a plan to complete all IP training by 1/1/2021 and he is about half way done. Martha stated Travis has completed the Administrator courses, Dementia Training Courses, and IP modules pertaining to RCFE. RO has received documentation of Dementia courses being completed and requested documentation of the Administrator course(s) completion as well as the IP course(s) completion. LPA requested documentation of the recommendations from LHD for the ED to return to work. Kitchen was observed to have ample supply of properly stored foods and refrigerator temperature logs completed. Observed two unlocked drawers to the right of the kitchen sink housing knives.



Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 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: 12/24/2020
NARRATIVE
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Continued from 809.

LPM reviewed Dementia Plan of Operation and areas observed to not be incompliance with the plan. The plan stated resident routines will be individualized in the care plans and based on the reappraisals reviewed they are similar and not individualized. Plan states training for any staff working with Dementia residents will complete 20 hours of initial training and 8 hours yearly of specified Dementia care training. Dementia plan states training will be suspended because of COVID, LPM requested this statement be removed as there is already a training provider coordinated and it can be done remotely. Plan states all dementia residents will have a written biography available for care staff and biographies were not observed. Plan states there will be 5 daily actives planned per day including an exercise program identified in the care plan, at this time there is no activity calendar posted and group activities are not planned. Technical assistance has been provided that activities should be offered based on individual preferences. In addition PINs were provided via email addressing the departments guidance related to activities during COVID. The Plan of Operation further states a formal reappraisal will be done after a hospitalization or observed change in behavioral, emotion, or physical needs. A formal reappraisal for resident one exhibiting observed changes in behavioral, emotion, or physical needs was not documented. Plan states residents with elopement risks wear ankle monitors and no residents observed to wear monitors at this time. Plan states there are security cameras, but there are none currently working in the facility, LPM requested removal of this if it in not in place.



RO’s previous request for proof of fire drill not received. Martha stated last fire drill was November 2019. Observed pictures of drill. Martha further stated that this was the last fire drill that was conducted.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/24/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2020
LIC809 (FAS) - (06/04)
Page: 2 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2020
Section Cited

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87468.1(a)(2) Personal Rights of Residents in All Facilities
Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met as evidenced by: Based on interview and observation Licensee left tools and ladder unattended in an area residents have direct access to and loose electrical cords were on the floor in a resident room 7 which poses an immediate risk to residents in care.
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Type A
12/28/2020
Section Cited

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87705(b)(2) Care of Persons with Dementia

The plan of operation shall address the needs of residents with dementia, including: Safety measures to address behaviors such as wandering…
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This requirement is not met as evidenced by: Based on interview and observation the exit doors on floors one and three are unsecured which poses an immediate risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2020
LIC809 (FAS) - (06/04)
Page: 5 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2020
Section Cited

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87705(j) Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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This requirement is not met as evidenced by: Based on interview and observation the exit doors on floors one and three are unsecured with no alarms to alert staff which poses an immediate risk to residents in care.
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Type A
12/28/2020
Section Cited

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87705(f)(1) Care of Persons with Dementia
The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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This requirement is not met as evidenced by: Based on observation two kitchen drawers housing knives were observed to be unlocked which poses an immediate risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2020
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/24/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/28/2020
Section Cited

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87705(k)(3) Care of Persons with Dementia
Fire and earthquake drills shall be conducted at least once every three months on each shift and shall include, at a minimum, all direct care staff.
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This requirement is not met as evidenced by: Based on records review and interview the last fire drill was conducted in November 2019.
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Type B
01/04/2021
Section Cited

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87705(7) Care of Persons with Dementia
An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation
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This requirement is not met as evidenced by: Based on interview and observation there is no scheduled activity plan that addressed the needs and limitations of residents which poses a potential risk to residents in care.
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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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 12/24/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/24/2020
LIC809 (FAS) - (06/04)
Page: 3 of 5