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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/08/2021
Date Signed: 01/08/2021 12:32:48 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:ABAN, RICARDOFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 24DATE:
01/08/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ricardo AbanTIME COMPLETED:
11:00 AM
NARRATIVE
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On January 8, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Microsoft Teams at 10am with Infection Preventionist Ricardo Aban.

Exercise program on scheduled at 10am exercise on Activity Calendar was not on schedule, Ricardo stated residents were eating breakfast. LPM provided technical assistance to ensure they folof the activity calendar.

Stand up meeting log was reviewed for 1/8/2021. Facility started to initial after they have read it from LPM's technical assistance on 1/7/2021. Discussed removing cloth towels, assigned responsibility to care staff and laundry staff to remove towels. Residents rooms observed on floor two and three, cloth towels removed and provided clean towels for resident in her dresser.

One resident does not have access with soap in room 8. Staff were complaining residents soap dispenser broke yesterday and it was reported to Travis but not fixed, no access for resident to use soap. RO requested copy of resident's care plan. Room 10 observed and pulled emergency cord at 10:41am, response time for staff to return to the room was 5 minutes. Shared restroom for room 9 and 10 was observed with no paper towel dispenser or access paper towels.

Resident observed complaining of pain. Repositioned and staff stated she is ok afterward, staff stated she did not want to take pain medication. After thirty minute she was no longer in pain and stated she was doing ok. Observed hourly log was completed for the day by caregiver.

Residents moving all nonambulatory residents to floor two and ambluatory residents to floor three. Ricardo stated they are in with perspective residents.

Deficiencies were observed and given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Ricardo. A copy of this report was provided to Ricardo via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Ricardo is print out the report and fax a signed copy to LPA at 916-263-4744 or email to LPA at ashley.boothe@dss.ca.gov.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/09/2021
Section Cited

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87307 Personal Accommodations and Services (a) Living accommodations shall
(3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident. (D) Hygiene items of general use such as soap and toilet paper.
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This regulations was not met as evidenced by the facility did not provide one residnet access to soap and two residents access to paper towels which poses an immediate risk to residnets 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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 01/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/08/2021
LIC809 (FAS) - (06/04)
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