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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/09/2020
Date Signed: 01/04/2021 09:07:35 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 CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 25DATE:
11/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Travis Wyckoff, Licenssee/AdministratorTIME COMPLETED:
11:15 AM
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 On November 9, 2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, and Department of Public Health, Health Facilities Nurse Evaluator Rebecca Rebekah Bird- Wohlgemuth conducted an announced case management visit via Zoom. The team met with Maria Cantoria Temporary Manager and Travis Wyckoff licensee/ Administrator

During the tele-visit, the following information was confirmed; census onsite today is 25 (19 positive (cleared) and 5 negative), one resident is currently hospitalized, anticipated discharge date 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 as compared to three reported on the line list. Six residents remain on hospice five are stable, one is symptomatic. Last positive 10/18/2020. Three residents continue to be monitored, one of which requires a swallow eval that has been requested, one is liquids only and one has difficulty breathing and is reportedly not doing well status post possible drug use and AWOL.

The following areas were observed: The front door and screening area, three of three floors, the interior of three resident bedrooms and restrooms, communal restrooms and hand washing basins, the laundry room, and the dining area on the main floor. Two residents were observed in bed, the third was seated in a wheelchair. During the tour, the following concerns were observed and require follow-up; the Licensee reports that a workorder has been made for an upgrade in the telephone system for Thursday November 12, 2020. The team discussed the importance of a working telephone system that allows for outgoing and incoming calls to be tended to. The facility reported that there are currently four working lines, and one hand held cordless phone in the building. When residents are using the cordless phone, staff may not be near or in hearing range to hear the office lines ringing. The current policy is for staff to answer the phone within three rings. The facility will submit a plan to the department by end of day November 9, 2020 to ensure that the telephones will be answered in a timely manner.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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: 11/09/2020
NARRATIVE
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On the front door, there is a notice for guests to contact the main line, however due to the limited phone lines another plan should be implemented. There is a doorbell present and the facility agreed to follow up on its working order. The status will be requested during the daily call on Tuesday November 10, 2020. Also observed during the visit were handwashing basins without the proper signage. The Department requested that the signage be put up and will be followed up on during the unannounced visit later this week. In the laundry room, the department observed soiled linen on the floor. The Department requested a procedure to be put in place to avoid soiled laundry contaminating surfaces. Please provide the procedure and a staff training log by Thursday November 12, 2020. The current disinfectant solution used is Zepp with a sit time of 10 minutes. The Department requested that the sit time be added to the outside of the bottles for a visual reminder to staff. Follow up on this will be conducted during the unannounced visit later this week. The dining area was observed with chairs staked on top of one another. The Department requested that chairs allow for social distancing throughout the facility. Any chairs that are stacked need to be removed due to safety concerns. Large trashcans were observed in the hallway without lids, the Department requested the trashcans be removed. Follow up that this has been remediated will occur during the unannounced visit later this week. The facility will begin surveillance testing of 25% of existing staff, 25% of new staff and 25% of residents today. Discussion regarding the mitigation plan occurred, the Department requested a draft mitigation plan to be submitted by end of day today November 9, 2020.


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 MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 11/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2020
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: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2020
Section Cited

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Personal Rights of Residents in All Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:
(9) To have communications to the licensee from their representatives answered promptly and appropriately.
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This regulation was not met as evidentced by: The licensee did not ensure that the residents had communications answered promtly. Based on observation the telephone was not answered promtly.
This posses a potential risk to resients in care.
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Type B
11/09/2020
Section Cited

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Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times.
(1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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This regulation was not met as evidentced by: The licensee did not ensure that the facility was maintained in a clean and sanitary condition.
Based on observation,soiled linen was observed on the laundry room floor.
This posses 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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 3 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: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2020
Section Cited

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Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows:
(1) Solid waste shall be stored, located and disposed of in a manner that will not permit the transmission of a communicable disease or of odors, create a nuisance, provide a breeding place or food source for insects or rodents.
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This regulations was not met as evidenced by the facility failed to store solid waste in a manner that will not permit the transmission of a communicable disease or of odors. Based on observation there were two large trashcans in the hallway without lids. This posses a potential risk to residents in care.
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Type B
11/09/2020
Section Cited

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Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(3) All persons shall be protected against hazards within the facility through provision of the following:
(B) Information and instruction regarding life protection and other appropriate subjects.
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This regulations was not met as evidenced by the facility failed to protected against hazards within the facility by providing information and instruction regarding life protection and other appropriate subjects. Based on observation the facility failed to post signage for proper handwashing.
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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
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: 11/09/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/09/2020
Section Cited

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Personal Accommodations and Services
(d) The following space and safety provisions shall apply to all facilities:
(2) The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment.
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This regulations was not met as evidenced by the facility failed to provide a safe and healthful environment. Based on observation the facility had chairs stacked in the dining area which created a potential risk for the resients.


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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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:
DATE: 11/09/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2020
LIC809 (FAS) - (06/04)
Page: 5 of 5