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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/15/2021
Date Signed: 01/15/2021 04:40:53 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:
01/15/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ricardo AbanTIME COMPLETED:
11:15 AM
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On January 15, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Teams at 10am with Infection Preventionist Ricardo Aban and executive Director Martha Estalano. Census 24.

SIR was submitted to Sacramento South Regional Office (RO) on 1/15/2021 to report Resident one (R1) elopement from the facility at 3 am on 1/14/2021. During 3 am rounds Staff one (S1) discovered R1 was not in her room. Staff two(S2) and Staff three (S3) were notified along with live in care staff. S1 was on break and S2 was on floor three and S3 was on floor two attending to other residents, leaving floor two unsupervised. Internal investigation noted Staff four (S4) did hear the door alarm but stated they assumed it was staff taking out the trash as they usually do. Staff notified Licensee, Executive Director, Resident Care Director and resident’s responsible party. After searching the facility R1 was found outside on the sidewalk and S1 assessed R1 for injury and called 911. Paramedics transferred R1 to the hospital. R1 was admitted for a fractured pelvis from an unwitnessed fall during elopement. LPA and LPM reviewed R1’s LIC602 and Care Plan to observe R1 is unable to leave the facility unassisted. Ricardo stated they have changed policies and completed training for staff for taking out the trash during AM/PM shifts and caregivers need to be on floor two at all times. Training logs submitted to the RO on 1/15/2021.

Observed stand up meeting notes for 1/14/2021 ad 1/15/2021 included NOC shift notes, resident elopement, nurse notes and reminder to staff to be diligent and consciousness. LPA Interviewed Staff five (S5) on in service training topics to include early warning symptoms and prevention of elopement, operations changes to dispose of trash at 6:30am and 10:30pm, and staff will stay on the main floor and prioritize residents needs if there are two calls at the same time. S5 stated he did not hear the alarm go off in his room is on the other wing. S1 woke S5 to assist in looking for R1.

continued on 809 c.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
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 3
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: 01/15/2021
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continued from 809.

LPM provided technical assistance to review the Dementia Care Plan of Op to ensure the facility is following the plan to meet the needs of the residents safety for elopement including ankle bracelets and cameras. Ricardo stated there are instances where the ankle bracelet system is not operational right now. Ricardo stated he had a conversation with Licensee that the facility is not capable of holding residents with known elopement risks and Licensee agreed. Ricardo was unaware this was the third elopement since September 2020. LPM provided technical assistance for Project Life Savor, a free program with GPS tracking systems for residents with Dementia (925) 256-3583.

The team observed red zone and discussed the plan for R1 to return to the facility into quarantine. LPA provided technical assistance to review Mitigation Plan and plan to provided designated care staff. Ricardo stated they would request 1:1 care for persons in the red zone. Room 42 observed, activity calendar posted and no cloth towels present in restroom. Ricardo stated COVID vaccine for 20 staff were administered last week. No known date for resident vaccinations currently.

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: 01/15/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 01/15/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/16/2021
Section Cited

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Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
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This requirement is not met as evidence by: record review and Interview, R1's Physician's Report indicates R1 cannot leave the facility unassisted. Facility did not ensure supervision was provided to R1. This poses an immediate health and safety risk to clients in care.
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Type A
01/16/2021
Section Cited

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87705(j) Care of Persons with Dementia
The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.
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This requirement is not met as evidenced by: Based on interview the exit doors alarms to alert staff were souned heard by staff and ignored by staff which poses an immediate health and safety risk to residents 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: 01/15/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/15/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3