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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 09:35:36 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:
11/11/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Travis Wyckoff, LicenseeTIME COMPLETED:
03:30 PM
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On November 11, 2020, Licensing Program Manager (LPM) Liza King conducted an follow up telephone call at 2pm. LPM met with Maria Cantoria Temporary Manager (TM) and Travis Wyckoff licensee/ Administrator.
During the TA, the following was addressed based on previous Technical assistance and/or citations issued: Discussion regarding plastic vs. mesh laundry bags was differed until a nurse is on the call, additional training of staff was discussed as it relates to the disinfectant used and discussion was had regarding the previously observed shampoo container and bar soap in a dementia residents room. The Department recommended that a staff member take a basket throughout the memory care area to remove similar items. The TM mentioned that she would like the three Administrator(one from each shift) to be a part of the TA visits and telephone calls. The Department agreed to the request and recommended having these staff members review and be responsible for various areas that have been previously cited. The TM mentioned that Travis has implemented a standup meeting with each shift. The Department recommended that new policies can be placed in a communication log or be posted by the timeclock to further reiterate new practices. Follow up was provided regarding the new phone service and a contract was entered into. The facility will notify the Department when I work order has been completed.
Discussion occurred regarding the two readmissions. One resident is having a difficult time adjusting, she has moved rooms does not have a tv and is anxious and agitated the facility has a prn and have reached out the MD and psychiatrist. This resident is in a private room and private bathroom at the end of a hallway. The other resident that returned today is in a shared bedroom with no roommate and a shared jack and jill style bathroom. The resident that she shares a bathroom with is nonambulatory and incontinent and will not be using the bathroom area.
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: 11/11/2020
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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. The facility will revise their Mitigation plan based on LHD current guidance and will submit no later than COB Monday, November 19, 2020.


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)
Page: 2 of 2