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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 02/10/2021
Date Signed: 02/11/2021 06:44:21 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: 26DATE:
02/10/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Ricardo AbanTIME COMPLETED:
10:30 AM
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On February 10, 2021, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, and Licensing Program Analyst (LPA) Jamie Vado conducted an unannounced case management visit via Teams at 9am with Infection Preventionist Ricardo Aban and Executive Director Martha Estalano.

Current census 26. Ricardo stated there have been no new resident incidents. Two residents cleared from the Red Zone and there is one resident remaining in the Red Zone until 2/13/2021.

Floor three observed. The red zone entrance is partitioned at hallway entrance next to room 16 with a wall mounted hand sanitizer and all COVID precaution signs posted. Staff one (S1) was observed cleaning Room 16 using Zep with 3 minute sit time and stated he is using one capful bleach to one gallon of water and changing the mop buckets and twice daily. LPM sent email with bleach dilution instructions again and requested Ricardo provide staff training and provide the RO with proof of all staff training by 2/12/2021. Observed room 17 with doffing signs and instructions, touchless trashcan for discarded PPE, resident reminder on door to ask for assistance and keep the door closed, a lined laundry hamper, extra linens and incontinent products stored in the closet. Ricardo stated each room now has a TV. Observed room 17 restroom with handwashing sign, soap, paper towels, and touchless covered trash can. PPE station observed and Ricardo stated PPE stored in the Red Zone is at least a 14 day supply. Ricardo stated he placed an order for 400 more PPE and stored in Red Zone. Wipes observed and Ricardo stated they are tamper proof for residents. Staff break room observed and restroom with handwashing sign, soap, paper towels, and touchless covered trash can. Ricardo stated designated staff enter clean through main facility entrance and enter red zone through partition between rooms 3 and 5 and then at the end of their shift exit though exit door between rooms 17 and 18. Observed a variety of wipes with different sit times and LPM recommended Ricardo provide training on the different sit times to staff. Resident room18 observed to be closed with sign posted of when residents start and stop isolation. Designated staff caring for red zone residents are staying at a hotel. At 9:29am observed room 10 with a plug and electrical cord run in between a notch in the door jam and the exit door to the patio and plugged into an exterior electrical outlet, while no damaged was observed on the cord, LPA recommended to have an electrician ensure it was not hazardous. During exit interview Ricardo stated they have removed the cord. Observed exit door between rooms 8 and 9 locked with a working alarm turned on.

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 02/10/2021
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Continued from 809

Floor two observed. Designated locked entry on Clinton Street with signs posted for COVID and visitor policy, hand sanitizer and extra PPE. Designated staff screener requests visitors practice hand hygiene and the team observed Staff two (S2) screen and document updated CDC COVID signs symptoms. Observed separate log for staff and visitors. Ricardo stated only essential workers and maintenance workers are allowed inside. Ricardo stated the activity for 10am today is morning stretches and observed staff moving residents towards the activity room. Observed dining room with residents socially distanced and wearing masks if not eating. Ricardo stated current dining practices are designated one person per table, disinfected in between use with Zep and Staff three (S3) stated she cleans the table with Zep and lets it sit for 3 minutes. Observed door visit set up and patio. Ricardo stated door visits are scheduled, residents and staff are provided with headphones, visitors are screened at the door visit and have a designated visitor log. Observed exit door between rooms 17 and 18 locked with a working alarm turned on. Room 37 observed and hand soap observed in locked cabinet and staff are assisting residents with hand washing. Room 38 observed and hourly log observed staff last repositioned resident at 8am and she was not complaining of pain. Observed exit door at room 38 locked with a working alarm turned on. Kitchen observed and Ricardo stated lunch today will be turkey sandwiches. Observed locked drawers for knives and ample supply of properly labeled and unexpired food in the refrigerator. Ricardo stated staff food is kept downstairs in separate refrigerator.

Elevator inspection is due 2/27/2021, Travis requested inspection but it has not been scheduled.

Floor one observed. Both common restrooms observed with hand washing sign, soap, paper towels, and touchless covered trash can. Observed toilet paper holder repaired after 2/8/2021 visit. Ricardo stated Travis is in charge of the maintenance and repairs. Ricardo stated as he does rounds he takes pictures and requests maintenance from Travis. Rozz manages the finances, budgeting, and hiring of employees in the facility. Staff break area observed with signs for social distancing, wipes, and one chair per table. Laundry room observed with chemicals locked and properly stored and no linens on the floor. Dry food storage area observed clean, organized and food in ample supply.

Exterior patio and garden observed with social distance signs posted and hand sanitizer available. Ricardo stated the staff and residents maintain social distancing.

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: 02/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2021
LIC809 (FAS) - (06/04)
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