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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/12/2020
Date Signed: 01/04/2021 09:31:57 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: DATE:
11/12/2020
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Travis Wyckoff, Admin.TIME COMPLETED:
02:30 PM
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On November 12, 2020, Licensing Program Manager (LPM) Liza King, Regional Manager (RM) Krystall Moore, 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 1pm. The team met with Maria Cantoria Temporary Manager and Travis Wyckoff licensee/ Administrator.

During the TA, the following was confirmed, current census today 26; 21 positives of which 19 have cleared and 5 that are negative. One resident remains in the hospital and may require a higher level of care per the conservator. Two residents returned from SNF placement yesterday. The facility reports that one resident is stable in shared (no roommate) bedroom and a shared bathroom. However, based on the Departments recommendations the day prior, the facility has arranged for this resident to share a restroom with a dependent resident whom does not use the restroom. This decision occurred after the previous days discussion regarding the risks of residents sharing a restroom while on isolation. The other readmission is in a private bedroom with a private restroom. This resident is having a difficult time adjusting to isolation, is reportedly refusing to stay in her room, refusing to wear a mask and can be verbally aggressive. Discussion regarding triggers, approach, redirection, incentives and engagement occurred. The facility has spoken with the MD and it was recommended to request a virtual appointment with the psychiatrist. The Department also recommended a 1:1 caregiver. The facility reported that there are several staff that work well with the resident. The facility reported that they had followed with LHD and these two individuals only need to quarantine until 11/15/2020. The facility will follow up regarding the communal dining and activities with the LHD.
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)
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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: 11/12/2020
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Discussion regarding plastic vs. mesh laundry bags was provided and the PCC agreed the facility can use plastic bags for active positive residents and mesh bags for other residents however, heavily soiled items should still be placed in plastic bags and mesh bags will bed to be washed with each load of laundry. A contract has been entered into regarding the phone lines, there will still be 4 lines but there will also be 4 cordless and 10 stationary phones added throughout the building. The work order for this will be confirmed. A replacement doorbell has been purchased and installed.

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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