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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/11/2020
Date Signed: 01/04/2021 01:01:26 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:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: DATE:
11/11/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Travid Wyckoff, Admin, LIcensseeTIME COMPLETED:
10:25 AM
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On November 11, 2020, Licensing Program Manager (LPM) Liza King, <Licensing Program Analyst Ashley Boothe 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 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, the facility receives updates via his case manager or conservator, pt is stable and reportedly may need a higher level of care per the conservator. There are two residents that are in a SNF that will be discharged today back to the facility. Discussion regarding the placement of the residents occurred. According to Travis, one resident has a private bedroom and bathroom that she will be returning to and may have a private caregiver. The other resident will be returning to a room that has a shared bathroom. Recommendations from the Department were that the two individuals do not share a bathroom, and the resident that is more compatible use a bedside commode during this time and wash basin. Further follow up will be provided regarding the readmissions as the process occurs. The facility has had six deaths. Travis requested that the call be cut short as he has another call and prefers the calls to occur in the afternoon instead, so that he has more updates of the resident’s wellbeing throughout the day. LPM will arrange for later calls. 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 facility and the conservator for hospice. Last positive 10/18/2020. Three residents continue to be monitored. There are no reported staffing shortages and no need for additional PPE. The LPM will call the facility again this afternoon to follow up on the readmissions.


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

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
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 2
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: 11/11/2020
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During the call the LPM reviewed PIN 20-38 with Travis and the TM as it relates to individuals that have already been isolated at the hospital. The LPM requested that the facility reach out to Genie from the local health department for guidance regarding the number of days these two individuals need to isolated for. In addition, the LPM requested that the facility inquire with the health department regarding communal dinning as it appears that more stringent requirements may be ordered. The facility conducted its surveillance testing and has not received results.

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

DATE: 11/12/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2020
LIC809 (FAS) - (06/04)
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