415600927-1-7-2021-14-AS-ABOE-BX2V8A-20210107151225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/07/2021
Date Signed: 01/07/2021 03:28:19 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 CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	ABAN, RICARDO		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 24	DATE:	01/07/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban and Martha Estalano		TIME COMPLETED:	02:00 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

On January 7, 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 all negative, no one showing signs or symptoms. Census 24 onsite, one resident still at the hospital. Resident who had a fall was on the phone with PCP, unable to interview today.

Stand up meeting notes on 1/7/2021 hosted by Travis discussed resident moves, residents’ updates, exercise plans for the day and staff reminders about sanitization. Observed inconsistency in written communication to keep the information discussed. LPA provided technical assistance to document so all staff received linear communication. Staff have access for the log and LPM provided technical assistance to read through the log, and initial after they have read it and to include any operation changes in the log.

LPA reviewed PIN 20-48-ASC, Mitigation Plan LIC808, and Dementia addendum to be submitted to LPA by 1/24/2021.

Martha stated Dementia Plan of Operation is being worked on by Susan. LPA recommended to review as a team and send a final version to the RO when completed. Activity calendar reviewed. Staff stated at 10am activity 4 residents came this morning, two activities scheduled this afternoon, designated staff was able to provide details on the plan for the day. Dementia Plan of Operation states activities are based on resident’s lifestyle. LPM provided technical assistance integrating additional small group activities as outlined in the Dementia Plan of Operation based on lifestyles and individual preferences. Standard practice is to post in all resident rooms, Martha stated Susan will get it posted tomorrow.

Medication audits review, other staff completed daily audits as assigned on Saturday and Sunday. Ricardo stated he checks it daily and if it has not completed, he will complete at the end of the day. All audits completed from 12/17/2020. MARS were reviewed, requested two residents records. MAR’s month signature and initial identifiers not documented on the back. MAR for one resident received PRN, effectiveness documented for December, no PRN given to residents in January thus far. LPM provided technical assistance to include on daily audit evaluate the effectiveness of pain medications and any refused medications.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

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: 01/07/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Phone system upgrade is almost completed and wifi is now available throughout the facility.

Room 14, 42, and 50 observed. Two restrooms observed cloth towels, one private, one shared. LPM provided technical assistance to provide multiple folded, clean towels in resident’s drawer to use as a single use and then dispose of in the hamper after use.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2