415600927-2-4-2021-14-AS-ABOE-BXX3YY-20210204174044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 02/04/2021
Date Signed: 02/04/2021 05:41:07 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: 26	DATE:	02/04/2021
TYPE OF VISIT:	Case Management - COVID-19	UNANNOUNCED	TIME BEGAN:	04:15 PM
MET WITH:	Susan Ladeza and Ricardo Aban		TIME COMPLETED:	05:45 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 February 4, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an unannounced case management visit via Microsoft Teams at 4:15pm with Office Manager Susan Ladeza and Infection Preventionist Ricardo Aban. Current census 26. Susan stated they completed an in service training around incontinent care today during the stand up meeting. Susan stated no residents incidents since last week. Ricardo stated all staff were COVID tested on 2/3/2021, results pending. Resident one (R1) and Resident two (R2) in Red Zone will clear 14 day isolation on 2/9/2021 and Resident three (R3) new admission will clear on 2/12/2021. Susan stated Resident one (R1) is having regular hallucinations and is redirected back to her room. R1’s reappraisal of needs and services plan has been completed and R1 has been identified to not require 1:1 care at this time. LPA requested a copy of R1’s needs and services plan be sent via email by 2/6/2021. On 1/28/2021 visit R1 was observed on out of her room and the bedroom door open, new Red Zone procedures for so residents are able to move around freely. Facility is in the process for change in procedure and retraining staff to follow new procedures of donning and doffing outside the partition, staff training will be completed at LPM's recommendation. Ricardo stated staff training for disinfection practices last occurred the end of last week. Ricardo stated he will send a copy of the update Operations Manuel to LPA for review. Observed R1 and R2’s hourly log checks hard to read and will be sent via email by 2/6/2021 to LPA for 2/3/2021 and 2/4/2021 for review. 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: 02/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021

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: 02/04/2021

NARRATIVE

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Continued 809.

Observed Red Zone in clean and sanitary condition. Observed new donning station outside Red Zone partition to be stocked with PPE supplies, PPE guidance and Stop signs posted, touchless covered trash can to dispose of N95's, hand sanitizer mounted on the wall, and a walkie talkie for staff to communicate. Ricardo stated he now has his own account to order PPE supplies and taken responsibility for keeping 14 day supply on hand. Ricardo stated the same designated staff will continue to care for new admission and still reside in a hotel. Staff one (S1) observed wearing N95 mask only in common area. LPA, LPM and Ricardo discussed the need for staff to wear full PPE in common area if residents will not follow isolation procedures. R1 observed in bedroom with door closed, then opened her door and S1 redirected her to close it. R2 observed in bedroom, observed an empty trash can with out a lid in room and Ricardo moved it out and stated he will replace it with a touchless covered trash can, he is not sure where it went. R3 observed in bedroom with the door open, Ricardo closed it upon exiting the bedroom and reminded R3 it needed to remain closed, R3 acknowledged understanding. R2 and R3's restrooms were fully stocked with all supplies, hand washing signs posted, and toxins secured.

No deficiencies were cited on today's visit. 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: 02/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2021

LIC809 (FAS) - (06/04)

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