<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 12/31/2020
Date Signed: 12/31/2020 04:47:30 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:
12/31/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Martha Estalano and Ricardo Aban.TIME COMPLETED:
12:15 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 31, 2020, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Microsoft Teams at 11am with Executive Director Martha Estalano and Infection Preventionist Ricardo Aban. Martha stated all 24 residents and 13 staff tested on 12/30/2020, results pending. Other staff were tested on 12/21/2020, results negative. Line list was reviewed, resident was at a Good Samaritan moved to the ER for low O2 saturation, completed lab work and put a hold on medication. Martha stated she will update the resident line list.

The team observed the exterior of the facility and entrance and exits to follow up on deficiencies cited on 12/24/2020 pending correction. Observed exit door in lounge on floor two to have the alarm disable and an unlocked door on floor two. POC not cleared at this time for previous citations. Staff one (S1) stated two residents like to go outside to garden and staff take smoking breaks out there. In the garden patio furniture in did not encourage social distancing, disinfection and sanitization supplies were not observed, and there was a pallet and tables folded up leaning against the building in the garden causing a trip hazard for residents using the garden. Items to be donated including, tables, chairs, walkers, wheelchairs, lamp shades, plastic totes, and mirrors were observed along side yard of the facility. S1 stated these items were pending donation pick up. They were not in an area regularly used by residents but in an area residents have access to behind a latched but unlocked gate off the garden. Phone system wires were observed to be exposed and a potential hazard in the side yard. The patio where visitors and residents use for visits was observed with clutter and chairs not compliance with social distancing requirements. LPA provided technical assistance to move furniture, provide social distancing signs, and sanitizer for use in the garden and on the patio. LPM provided technical assistance to post signs at all exits to ensure staff and visitors are directed to enter through the main entrance. One entrance off the ramp for floor two is used to medical transport in and out and deliveries. LPM recommended to put a sign to state what that entry is used for but visitors need to be screened at main entrance.
Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
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 3
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: 12/31/2020
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.

Ricardo stated they conducted the fire drill yesterday by showing Race and Pass video training and stated a Physical Training of Evacuation is scheduled for next week. LPM recommended to make it into an activity for alert residents to help and encourage everyone to participate. POC not cleared at this time for previous citations.

Kitchen was observed and the sharps were secured in a locked drawer. Other utensil drawers were unlocked but knives were not observed in them.

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

DATE: 12/31/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/31/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/01/2021
Section Cited

1
2
3
4
5
6
7
80087(a) Buildings and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: The team observed tables, chairs, walkers, wheelchairs, lamp shades, plastic totes, and mirrors stored along the side yard which poses an immediate risk to residents in care.

8
9
10
11
12
13
14
Type A
01/01/2021
Section Cited

1
2
3
4
5
6
7
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.
8
9
10
11
12
13
14
This requirement is not met as evidenced by: The team observed pallet and tables folded up leaning against the building in the garden which poses an immediate risk to residents in care.
8
9
10
11
12
13
14
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: 12/31/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/31/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3