415600927-1-22-2021-14-AS-ABOE-BXHQW3-20210122113115

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/22/2021
Date Signed: 01/22/2021 11:31:38 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 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: 23	DATE:	01/22/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ricardo Aban		TIME COMPLETED:	11:30 AM

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 22, 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. Census 23. 25 with one transferring to a rehabilitation facility and one is hospital. No changes in condition for residents. 22 residents and 8 staff will attend vaccination clinic in the facility today. One resident submitted to hospice, currently 6 Hospice residents in the facility. Ricardo stated they are working on LIC 808 Dementia Plan addendum due to LPA by 1/24/2021. Ricardo stated there is not an update to finding a reliable vendor alarms system or ankle bracelet solutions, but he is in contact with Project Lifesaver. Dementia Plan of Op is under revision and will be sent to LPA once completed. Observed the screening process. Facility has single entrance through locked front door. Signs posted on front door. Designated staff answers the door, takes temperature outside prior to entry, staff request to sanitize hands, designated staff document in screening log, travel, exposure, symptoms in shortness of breath, cough, loss of smell, chill, headache, muscle pain and have visitor sign off. Ricardo stated if nurse from Home Heath agency comes, they are required to bring PPE. They don PPE outside by the front door including gowns, N95, face shield, and gloves. They are changing gloves before providing care to resident. While scheduling Home Health visits they request nurses to come that have not been to a COVID positive facility recently. Personal visitors call to make appointments, Staff arranges the visit and coordinates with caregivers to observe the visits. Visits last for no more than 30 minutes. Screening for visitors takes place on the visitor patio and staff take the visitor log to the patio to complete the process while maintain social distance. So far no visits have been ended short for violation of procedures and expectations are communicated to visitors prior to coming to the facility. Maximum is two visitors at a time on the patio to maintain social distancing. Door visit protocol is posted on the main front door. There are usually two scheduled door visits in the afternoon. Bedridden residents do facetime visits. Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

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
	VISIT DATE: 01/22/2021

NARRATIVE

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Continued from 809.

Ricardo stated in services training is based upon needs and occurring weekly, Ricardo stated last week three trainings were completed and Office Manager replicates Ricardo’s training on Sundays for weekend staff. Office Manager created a list of trainings, but the list is modified to included other trainings as needed by the facility, for example elopment training last week. Donning and Doffing training is scheduled for today, it was last completed in the beginning of January. Trainings are supplemented during stand-up meetings. PPE return demonstrations are random, and Ricardo observes one staff weekly. LPA provided technical assistance to make a list so all staff go through the return demonstrations. Medical Technician staff completed IP certification last week but wants to stay in role as Medical Technician but Ricardo is encouraging him to take a new role as IP. Ricardo stated they are looking into training additional staff as well. LPA observed staff Donning and Doffing sanitizing, gown, N95, seal check, face shield, sanitizing, and gloves over gown. Doffing inside the room, removal of gown, and rolled into gloves, discarded, sanitize, removal of face shield and N95 discarded, and sanitize. Ricardo stated they have watched instructional videos provided from CCLD frequently.

Disinfection practices are discussed during the stand-up meeting. In depth cleaning occurs during the noc shift. Staff carrying Zep on them in their apron unless they are feeding residents. Aprons are washed two to three times weekly and stored in the laundry area. Ricardo requested all staff to wear an apron. LPA provided TA to wash daily and have extra supply for staff to wear if they become soiled.

Ricardo stated if “Persons Under Investigation” the designated staff person would be two of three caregivers based upon their performance, how they care for residents, their donning and doffing skills, and his assessment they are capable of doing no harm to staff or residents by following all Mitigation Plan procedures. Ricardo stated they would be short staffed in the morning if they needed to move staff to the red zone so Office Manager would reschedule to cover the shifts that would be short staffed. Facility is in contract with three staffing agencies to call upon if needed.

Floor three red zone breakroom observed, stocked with cleaning supplies and 14 day supply of PPE. Patio and garden observed from inside to have laminated social distancing, wearing a mask and secured to withstand the weather.

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: 01/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2021

LIC809 (FAS) - (06/04)

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