415600927-1-4-2021-14-AS-LKIG-BWXNQ9-20210104093936

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/10/2020
Date Signed: 01/04/2021 09:39:52 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	UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Travis Wyckoff, Admin. Licensee		TIME COMPLETED:	05:00 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 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 unannounced case management visit via Teams at 2pm. The team met with Maria Cantoria Temporary Manager and Travis Wyckoff licensee/ Administrator. During the TA, the following was observed and addressed based on previous Technical assistance and/or citations issued: The hand washing signage was observed in several resident rooms and in one communal bathroom. A laundry basket was observed in one resident room, which did not comply with the information that was provided during the morning call, laundry baskets will be lined with garbage bags to ensure that staff are not handling loose soiled laundry. The implemented procedure and a staff training log for the laundry procedure has been requested by Thursday November 12, 2020, per this mornings telephone call. Additional monitoring of this by the Department will occur during TA visits. The current disinfectant solution used is Zepp with an updated sit time of 3 minutes. During the TA visits as previously planned, a visual of the cleaning solution bottles was observed. Upon asking a ransom staff member to see their cleaning solution bottle, the Department observed the label “Spray Sit time 3 minutes then wipe off” During the TA visit it was recommend that the bottles also include the name of the solution and a clear plastic laminate be placed on the paper label to prevent ink bleeding, the facility executed the request immediately. The staff when asked, stated that the sit time was 10 minutes, additional training should be provided to the staff of the sit time of the disinfectant used. Observation of the dinning room, showed tables and chairs socially distanced. The TM stated the LHD informed the facility that they may resume communal dinning. The Department recommended at least 6 feet of social distancing and no more that one resident per table, the TM agreed. There were no staked chairs observed.

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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In addition to the above areas, the Department observed the following areas. On the main floor, a large seating area where residents were watching TV socially distanced, dining areas where residents were socially distanced, and residents ambulating about the common areas. Three resident rooms were observed, in the restroom of a dementia resident the Department observed a large bottle of shampoo and a bar of soap. Gloves and hand sanitizer were observed on the hand rails throughout the main floor in addition to common area boxes. The Department recommended that gloves be placed in resident rooms and staff carry sanitizer in pockets, to reduce the clutter in the common hallways and on countertop areas. The facility mentioned that the supplies could be mounted on the walls. Discussion occurred regarding the facilities plan to allow for new admissions. Follow up will be provided moving forward through the process to promote safe practices. The Department asked that the facility follow their mitigation plan and provide updates as necessary.

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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