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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/27/2021
Date Signed: 01/27/2021 01:52:29 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:
01/27/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Ricardo AbanTIME COMPLETED:
12:30 PM
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On January 27, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Teams at 11:30am with Infection Preventionist Ricardo Aban.

Census 25. Ricardo stated designated staff caring for residents in the Red Zone will be staying in a hotel. Licensee stated they already have the California Hotel Accommodations account set up and will coordinate accommodations for those staff as they are regular live in care staff in the facility. Ricardo stated he completed training with designated staff and has observed staff and residents in the Red Zone. Resident one is a new admission, happy to be in the facility, and adjusting well. Resident two (R2) is a returning resident from a higher level of care. Martha stated they have reviewed progress and discharge notes form the hospital. R2’s mental health issues are resolved and any ongoing incidents are considered behaviors at new baseline. Martha stated no behavioral instances have occurred since readmission. Martha stated they are in the process of reappraising R2’s needs and care plan. LPM provided technical assistance to assess the currant staffing schedule and identify if and how the facility can or cannot meet new level of care. Continue to provide documentation to responsible parties for any incidents. Ricardo stated both residents will isolate for 14 days following the facility's approved mitigation plan.

Communal dining room observed. Pastrami sandwiches and salad were served for lunch. Ricardo stated communal dining practices included one lunch service for all residents starting at 11am and four staff assisted in lunch service today. One resident at a table or tv tray and staff disinfect after after resident is done eating and moved away using Zep. Six residents require feeding assistance. Observed three staff in the dining area and residents seating one per table spaced out through the lounge, dining room, and activity area. Observed one resident not wearing a mask moving through the communal areas after lunch. Observed ample food supply properly stored. Sharps drawers in kitchen were locked and secured. Temperature of refrigeration units were 40 *F and 32 *F. One meal tray observed for resident in red zone who refused meal service today, Ricardo stated the food tray did not go into Red Zone and the process for delivering meal service to that area is to contact Red Zone care staff on the walkie and bring it to the Red Zone entrance, as the same process with medications.

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: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
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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