415600927-1-19-2021-14-AS-ABOE-BXEU8J-20210119142138

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/19/2021
Date Signed: 01/19/2021 02:22:01 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: 23	DATE:	01/19/2021
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	02:30 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 19, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an announced case management visit via Teams at 1pm with Infection Preventionist Ricardo Aban and executive Director Martha Estalano. Census 23. 25 with one transferring to a rehabilitation facility and one is hospital. Vaccine have been administered to 21 staff and 4 will go vaccinate on Thursday. Martha stated they have not received a date for resident vaccinations from either pharmacy. No changes for resident one, resident two will transfer from hospital to rehabilitation facility, and resident three was transported to the hospital and returned to the facility about three hours later, isolating in her private room, the facility is following SMCPH’s recommendation for return from higher level of care, and she will start hospice care. SIR was submitted to LPA on 1/15/2021. LPA provided technical assistance to review PIN 21-04-ASC included in follow up email for Ricardo and Martha to sign up for PINS to their emails. Ricardo stated they are reviewing and working on LIC 808 and Dementia Plan addendum due to LPA by 1/24/2021. Ricardo stated Project Lifesaver is not available in Redwood City, he will continue to follow. In-service Elopement training on 1/15/2021 to clear the POC due on 1/16/2021. During the meeting they conducted a simulation and the live in staff it is not able to hear the alarms, Travis is looking into alarms solutions. The ankle bracelets are not working and Rozz is working to find a reliable vendor. Staff identified residents who do not manifest wandering tendencies but have cognitive and physical ability to in the future. Ricardo stated any new staff would go through the elopement training provided to staff on 1/15/2021 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: 01/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

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: 01/19/2021

NARRATIVE

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Continued from 809.

Medication audits observed. All audits completed from 1/12/2021. MARS were reviewed, requested two residents’ records. MAR’s were completed for two residents. MAR for one resident received PRN, effectiveness documented for three dates. Centrally Stored and physicians order reviewed to confirm new PRN for resident as of 1/12/2021.

Patio area observed for window visits and garden observed. Chairs have been moved to 6 ft apart. No signs were posted and Ricardo stated they blew down in the last rain. LPA provided technical assistance to post signs to encourage wearing a mask and social distancing so they would not ruin in the weather.

Room 37, 33, 27 and 28 observed. No soap available in one resident restroom where staff are providing assistance for handing washing. Two hourly logs for residents were complete and filled out. Communal restrooms observed stocked with soap, paper towels, hand washing signs posted and locked cabinets. Laundry room observed with locked chemicals. Staff break room observed. LPA provided technical assistance to post signs to encourage social distancing and disinfecting 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: 01/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2021

LIC809 (FAS) - (06/04)

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