415600927-12-30-2020-14-AS-ABOE-BWT4SC-20201230182119

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/30/2020
Date Signed: 12/30/2020 06:21:52 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: 25	DATE:	12/30/2020
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Martha Estalano and Ricardo Aban		TIME COMPLETED:	10:45 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 30, 2020, Licensing Program Analyst (LPA) Ashley Boothe, Licensing Program Manager (LPM) Liza King and DSS Nurse Consultant Helen Shi conducted an unannounced case management visit via Microsoft Teams at 9:30am with Executive Director Martha Estalano and Infection Preventionalist Ricardo Aban. LPA provided verbal confirmation the facility has been sent via email and certified mail the Order to Remove Suspension of New Admissions dated 12/29/2020. LPA requested follow up on SMCPH guidance for ED return to work, Martha stated Travis is letting ED come back early and Ricardo joined the team on the visit. Ricardo stated SMPCH stated it was up to the employer for return to work. Rozz contacted Ricardo and requested he come back 12/30/2020. Line list was reviewed, no updates or incidents reported. Licensee Rozz Wycoff was on the vaccine webinar, contacted the pharmacy and stated the facility is scheduled for middle of January vaccines, working verbal notification and will send responsible parties the form for written authorization. Martha stated they are working on activity calendar by POC due 1/4/2020 and updated facility map by 1/9/2020. Staff and visitor screening area observed. Designated screening at reception area. Room 15 where resident had a fall last week, no physical obstructions or trip hazards were observed. Room 31 is no longer going to be used for PPE storage and supplies are moved downstairs. Staff restroom observed fully stocked and hand washing sign. Kitchen observed with locks on two drawers, LPA provided technical assistance that drawers must remain locked even if staff is in the kitchen and staff food should be stored separately and labeled. 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: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

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 2

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: 12/30/2020

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
26
27
28
29
30
31
32

Continued from 809.

Observed Red zone, rooms 16 and 17 observed lined laundry, extra linens available in closet, restroom observed to have soap, sanitizer, and signage posted, cloth towels observed Helen provided technical to add trash cans outside each room to dispose of N95 and a shelf with wipes to disinfect shield and sanitizer for hand hygiene. Designate signs for three categories for confirmed positives isolation, person of interest quarantine results pending, and quarantine new admission and plan for what each room is for prepare. Helen recommended a two week supply of PPE in storage closed and locked. Martha stated in hypothetical situation dedicated staff for positive but was not sure what to do for POI. Helen provided technical assistance to think through what the plan is for various scenarios including residents under isolation, quarantines for new admissions and POI. Observed two exit doors on floor three alarmed. Helen inquired about Ricardo providing PPE training, he stated he completed it before he left and Helen recommended return demonstrations for staff daily. Ricardo stated he contacted LPA Jamie Vado for additional PPE supplies and they were provided from the RO. PPE supplies on hand is two week supply and Ricardo stated Travis conducts inventory. Rozz provided first aide training but no Fire Drill has been completed. Martha stated she will contact to provide staff training for using the fire extinguisher. Physical fire drill was completed on 12/30/2020. LPA requested Ricardo update LPA when all staff and residents have completed a Fire Drill per the regulatory requirement. Three out of four exit door on floor one observed unlocked and unalarmed.

The Licensing report gave notice that the failure to correct the violation previously cited by the specified length of time would result in a civil penalty. Because you failed to make the correction by the date specified a civil penalty of $100 per day per citation shall be assessed until the violation is corrected.

87705(b)(2)
87705(j)
87705(k)(3)

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: 12/30/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2