415600927-1-4-2021-14-AS-LKIG-BWXNHX-20210104092928

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/16/2020
Date Signed: 01/04/2021 09:29:40 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:	11/16/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Travis Wyckoff		TIME COMPLETED:	03:00 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 16, 2020, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, DSS Program Clinical Consultant Helen Shi and Department of Public Health, Health Facilities Nurse Evaluator Rebekah Bird- Wohlgemuth conducted an announced case management visit via Zoom at 2pm. The team met with Maria Cantoria Temporary Manager, Travis Wyckoff licensee/ Administrator and Susan Leduza, Swingshift Administrator at the facility. During the TA, the following was confirmed, current census today 26; 21 positives of which 21 have cleared and 5 that are negative. One resident remains in the hospital and may require a higher level of care per the case manager. During this call, Travis informed the RO that the individual is not conserved and has a case manager that assists with needed resources. Per the line list today, the resident will not be allowed back. Also identified on the line list was a resident that had an unwitnessed fall, no SIR was received, according to Administrator she is fine and the SIR will be sent. The LPM confirmed that the appropriate eviction procedures need to be followed. The RO will monitor the placement of this individual on the daily calls. Two residents who were previously on quarantine have been cleared. There currently are six residents on hospice, three are monitored daily during calls due to their unstable condition. Surveillance testing of 25% was conducted last week all negative and testing was done today.

SUPERVISOR'S NAME: Krystall Moore	TELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:	DATE: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

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: 11/16/2020

NARRATIVE

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The facility has followed up regarding the communal dining and activities with the LHD, and at this time they are allowed. During the call, the RO requested the Administrator to explain the screening process at the front door which since Friday involves another assigned staff so that staff are not screening themselves. The RO requested a copy of the employee screening logs since Friday, November 13, 2020 in addition to the visitor log and screening log, a copy of the training logs for the past week and the Administrator is to send pictures of the PPE carts, green, yellow and red zone identification and PPE donning and doffing procedure signage posted. All requested items to be sent over by COB November 17, 2020. In response the facility visit on Friday, the Administrator confirmed during the call that all of the first aide and other hazardous chemicals have been collected throughout the building and locked in a secure area, the trip and fall hazards have been resolved, and the expired foods have been thrown out. In addition, the facility has eliminated the excess and unnecessary signage throughout the building and has begun cleaning the refrigerators. The empty touch free sanitizer containers have been removed and an order has been made for refills. In the staff break rooms, excess clutter has been removed as have extra chairs to allow for social distancing of staff. Cleaning wipes have also been placed in the break areas to allow for staff to clean the tables before and after eating. The RO briefly addressed the mitigation plan and the facility has reached out to the LHD and been provided approval for cloth masks on residents. The HFEN asked for the zones to be red instead of pink and the PCC asked for clarification on the COVID precautions of the staff in these cohorted areas. The RO also inquired of an ED and will continue to follow up.
No deficiencies were observed during today’s call. Exit interview was conducted with Travis Wyckoff where LPA 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 LPA 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: 11/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2020

LIC809 (FAS) - (06/04)

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