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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/04/2021
Date Signed: 01/04/2021 02:23:45 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: 25DATE:
01/04/2021
TYPE OF VISIT:Case Management - OtherANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Ricardo Aban and Martha EstalanoTIME COMPLETED:
02:30 PM
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On January 4, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Microsoft Teams at 1pm with Executive Director Martha Estalano and Infection Preventionist Ricardo Aban.

Results from mass tested 12/30/2020 are still pending, no one showing signs or symptoms of 24. At this time the department is no longer requesting the Line List to be reported via email daily. The facility is to continue reporting SIR’s to the Sacramento RO and provide verbal updated on the weekly calls to report any notable changes in conditions to residents in care. Resident had un witnessed fall in room 40 on 1/1/2020, admitted overnight to hospital, all tests normal, moved to second floor room 33 to monitor more closely and SIR will be sent to RO. LPA provided TA to move resident to the red zone and emailed PIN for review. LPM provided technical assistance to review mitigation plan and contact LHD to ensure all precautionary measures are taken. In the red zone Ricardo stated they have a plan for rooms 16 and 19 for new admissions and persons of interest and rooms 17 and 18 for confirmed COVID positive. Ricardo stated PPE supply was adequate, staff is taking over inventory and ordering, Ricardo stated he will train her on the burn rate calculator. Common areas, staff break area, garden, patio, lounge, hallways, rooms 29 and 38, and two shared restrooms were observed.

All staff have gone through fire drill training in January 2021, Ricardo stated the scenario was a gas leak. They used it as an opportunity as make it an activity. Building and grounds have been cleaned up and clutter removed. Observed multiple exit doors to be secured.

Activity Calendar is being developed and will submit to the RO today. Updated facility map will be submitted by 1/9/2021.

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: 01/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2021
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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