415600927-1-4-2021-14-AS-LKIG-BWXNNM-20210104093700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/10/2020
Date Signed: 01/04/2021 09:37:18 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:	WYCKOFF, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS:	DATE:	11/10/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Travis Wyckoff, Admin.		TIME COMPLETED:	11:00 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 November 10, 2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, and Department of Public Health, Health Facilities Nurse Evaluator Rebekah Bird- Wohlgemuth and Helen Shi, Program Clinical Consultant for Department of Social Services conducted an announced case management visit via Teams at 10am. The team met with Maria Cantoria Temporary Manager and Travis Wyckoff licensee/ Administrator. During the call, the following information was confirmed; census onsite today is 24 (19 positive (cleared) and 5 negative), one resident is currently hospitalized, unknown discharge date no updates provided during is 11/10/2020. There are two residents that are in a SNF and there have been six deaths. There is currently one resident that is symptomatic. Six residents remain on hospice five are stable, one is symptomatic. There is one additional resident that is awaiting coordination of MD and the conservator for hospice. Last positive 10/18/2020. Three residents continue to be monitored. Current staffing is 6/6 and 3 on this mornings shift there is reportedly 9 staff members. . A synopsis of the previous days call was provided by LPM King and the Administrator Wyckoff agreed to the following; a workorder has been made for an upgrade in the telephone system for Thursday November 12, 2020. In addition, the facility reported that a phone procedure was provided to the Department on November 9, 2020 to ensure that the telephones will be answered in a timely manner. The Department will follow up with the facility during a call later this week. The status of the door bell was inquired upon during the call today, the Administrator Wyckoff reported that there was an electrical issue which would be addressed by end of week

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

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: 11/10/2020

NARRATIVE

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The hand washing signage was addressed during the call and the Administrator stated the signage has been posted, the Department will follow up on this during a TA visit. The Administrator reported that a procedure had been established, that included garbage bags in laundry baskets, and large trash cans with lids that would be used to gather the bags of laundry from the rooms and transport the laundry to the laundry room. The trash cans will then be stored out of the resident area. Follow up by the Department on this process will occur during a follow up TA visit. Additionally, the Administrator reports that the housekeeping staff member is aware that soiled needs to be contained not loosely placed on the laundry room floor. The implemented procedure and a staff training log for the laundry procedure has been requested by Thursday November 12, 2020. The current disinfectant solution used is Zepp with an updated sit time of 3 minutes. The Administrator agreed during the call that the sit time has been added to the outside of the bottles. Follow up on this will be conducted during a TA visit later this week. The staked dining chairs were addressed during the call and the Administrator ensured that he had removed them from the dining area. Follow up will be completed during the next TA visit. The Large trashcans were observed in the hallway without lids, the Department requested the trashcans be removed, the Administrator ensured this had been completed. Follow up that this has been remediated will occur during the TA visit later this week. The facility will begin surveillance testing of 25% of existing staff, 25% of new staff and 25% of residents yesterday, 2 residents, 5 existing staff and 4 new staff were tetsed. A draft mitigation plan has been submitted to the Department for review.

No deficiencies were observed during today’s call. Exit interview was conducted with Travis Wyckoff where LPM reviewed report with Travis via telephone. An electronic copy of the report was emailed to the facility to obtain a signature from the Administrator and emailed back to LPM to be filed.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

LIC809 (FAS) - (06/04)

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