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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 01/28/2021
Date Signed: 01/28/2021 02:55:16 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:
01/28/2021
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ricardo AbanTIME COMPLETED:
01:00 PM
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On January 28, 2021, Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Teams at noon with Infection Preventionist Ricardo Aban.

Census 25.

Communal dining room observed. All residents observed finishing up lunch socially distanced seated either one person to a table to with a TV tray (similar to yesterdays visit). Observation of the kitchen included all drawers locked as necessary, hand washing signage and lid on trash can.
Tour continues to Red Zone. Resident one in redzone is in wheelchair at entrance of her room with her bedroom door open. Staff member was observed nearby without a mask or face shield on. According to staff member he was being called over the walkie talkie and had to remove hs PPE in order to be heard. Discussion occurred regarding the best placement of PPE station if residents are moving about the Redzone freely. Recommendation was provided to have PPE station prior to entry. Ricardo mentioned that if it becomes a concern the PPE station could be moved closer to the staff break area. LPM observed staff member Donn and doff with no recommendations. Ricardo has provided training three times this week and will provide training docs. LPM asked staff member the cleaning solution used for the area and SIT time, staff member replied Zepp with a 3min sit time. Staff also responded that they are using a bleach solution. I cup to one gallon, when LPM responded that the mixture was strong but would work, the staff member responded that they are using one cap full maybe a few tablespoons to a gallon. The procedure for a bleach solution needs to be clarified as this is not the first time that staff have responded that they are using a bleach mixture. LPM will provide Ricardo with the information via email.
SUPERVISOR'S NAME: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
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: 01/28/2021
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Resident two was observed seated in his room comfortable and happy. The restroom in R2s room had a hanging soap dispenser, hanging towel dispenser and the appropriate signage. No towels hanging in the area. Both exit doors opened on the second floor, alarms working. Room 50 observed with housekeeping cart, housekeeper present. Discussed disinfecting procedure and chemicals. Process is to clean with Betco PH7Q and let sit for 2 min, wipe then spray with zepp and let sit for 3 min then wipe. LPM pulled SIT time information from Betco website and provided via email to Ricardo. Current Sit time should be 10min for Betco. TA provided if facility is using Zepp there is no need to use Betco if they are only allowing the product to sit for 2min. LPM then observed Ricardo donn and doff successfully.

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: Krystall MooreTELEPHONE: (916) 263-4707
LICENSING EVALUATOR NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2021
LIC809 (FAS) - (06/04)
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