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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/13/2020
Date Signed: 11/13/2020 04:57:33 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:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 26DATE:
11/13/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Travis Wyckoff, AdministratorTIME COMPLETED:
04:45 PM
NARRATIVE
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On November 13, 2020 Licensing Program Analysts LPA's Ashley Boothe and Albert Johnson conducted an unannounced health and safety case management visit at 10:30am with Licensee /Administrator Travis Wykoff.

LPA's followed signs to a designated entry point on the second floor of the facility where COVID precaution and visitor signs were posted on the front door. LPA's rang the doorbell and were allowed entry to the facility by Travis who screened LPA's for temperature and symptoms of COVID-19. LPA's stated the purpose of the visit and were provided a facility map upon request. Ample amounts of sanitizer and PPE was available upon entry and down the main hallway. LPA's observed a Resident one (R1) without a mask on being pushed in a wheelchair by Staff one (S1) who then put a mask on R1 after LPA's identified themselves to Travis. LPA's observed staff screening log where staff are practicing self screening and not all staff are completing all screening questions. LPA's provided technical assistance to add an additional column to allow for a second staff to sign off to follow the screening protocols outlined in the facilities mitigation plan.

LPA's toured the second floor including the inside of resident rooms 32, 34, and 35. LPA's observed the cabinet lock to be broken leaving personal care items unsecured in the jack and jill restroom accessible to room 32. All restrooms observed had hand washing signs posted, soap and paper towels. LPA's observed Resident 2 (R2) in room 37 under quarantine order to not be wearing a mask with the door open. PPE was available outside the room, but PPE guidance postings were not immediately posted in the area where staff would be donning and doffing PPE.

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

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
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 6
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: 11/13/2020
NARRATIVE
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Continued from 809.

LPA's observed multiple deficiencies in the kitchen including improperly stored food, expired food, chemicals not secured in a food preparation area, Staff two (S2) not wearing a mask, and the Ansul/Fixed System requied of semiannual inspection compliance last checked on March 5, 2020. First aid kits were found to be unsecured in the dining room and on the third floor. The second floor lounge, dining room, and activity room were observed with tables with one chair positioned 6 feet apart and all residents were observed maintaining social distance while in common areas.

LPA's observed the Centrally Store Medications Log, Medications Administration Record (MAR), and PRN medications sheet with Staff three (S3). During the medication count LPA's observed and counted two medications for Resident three (R3) and Resident four (R4). Two of two medications were not accurate according to the Centrally Stored Medications Log and MARs.

LPA's toured the third floor and observed R1 in room 39 under quarantine order to not be wearing a mask with the door open. Upon LPA's request Travis closed R1's door. While down the hall, R1 was yelling and Travis entered the room to talk to her without donning any additional PPE other than the N95 he was already wearing. At this time R1 does not have a 1:1 care plan. S1 was the only staff observed in third floor hallway at the time caring for R1 and other residents in nearby rooms.

LPA's toured first floor including laundry room and staff break areas. LPA's provided technical assistance in the employee break room to move chairs away from tables to encourage social distancing and provide cleaning products for staff to use to disinfect surfaces in the area.

LPA's observed deficiencies in buildings and grounds including a shower curtain red being help up by a toilet paper roll and coat hanger and 10ft of telephone cable wrapped into a circle on the floor in resident restroom 50. Temperature in the facility was 72* and hot water measured at 118* in the restroom of room 50, both within rage of required temperatures.

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

DATE: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC809 (FAS) - (06/04)
Page: 2 of 6
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: 11/13/2020
NARRATIVE
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Continued from 809 C.

LPA's provided technical assistance to remove clutter, post signs in appropriate places for example post hand washing signs only in hand washing areas not in the hallways, and move PPE into more designated spaces with PPE guidance postings at each station.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. An exit interview was conducted with Travis. A a copy of this report was provided to Travis via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Travis 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: 11/13/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2020
LIC809 (FAS) - (06/04)
Page: 3 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2020
Section Cited

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87468.1 Personal Rights of Residents in All Facilities(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
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This requirement is not met as evidenced by: LPA's observed Staff one (S2) did not wear a face covering while providing care and supervision to residents in care in violation of official government orders requiring the wearing of face coverings while working under specified conditions. Staff screening practices not being followed according to facility's COVID Mitigation Plan which poses an immediate risk to residents in care.
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Type A
11/14/2020
Section Cited

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 87203 Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.
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This requirement is not met as evidenced by: The facility did not maintain in conformity with the regulations adopted by the State Fire Marshal. The "Fixed System" in the kitchen outdated. This system is scheduled for a semi-annual maintenance and was last serviced on March 5, 2020. Posing an immediate health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2020
LIC809 (FAS) - (06/04)
Page: 4 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2020
Section Cited

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (b) Medicines which are centrally stored shall be stored as specified in Section 87465 and separately from other items specified in (a) above.
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This requirement is not met as evidenced by:
LPA's and Licensee observed that toxins and cleaning supplies to be unlocked in residnet's bathroom cabinet, on PPE station on second floor hallway, underneath kitchen sink, and first aid kits in dining room and third floor hallway which poses an immediate risk to residents in care.
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Type A
11/14/2020
Section Cited

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80075(b)(5)(c) Health Related Services. The PRN medication record shall include the date and time the PRN prescription and nonprescription medication was taken, the dosage taken, and the client's response.

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This requirement is not met as evidenced by: LPA's and S3 observed during the medication count LPA's observed and counted two medications for Resident three (R3) and Resident four (R4). Two of two medications were not accurate according to the Centrally Stored Medications Log and MAR which poses an immediate risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2020
LIC809 (FAS) - (06/04)
Page: 5 of 6
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/13/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/14/2020
Section Cited

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87405(d) Administrator - Qualifications and Duties: (d) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
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This requirement is not met as evidenced by: Based on observation, the Licensee demonstrated lack of knowledge of and ability to conform to the applicable laws, rules and regulations this poses an immediate health and safety risk to residents in care.
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Type B
11/23/2020
Section Cited

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87555 General Food Service Requirements (9) Procedures which protect the safety, acceptability and nutritive values of food shall be observed in food storage, preparation and service.
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This requirement is not met as evidenced by: LPA's, Licensee, and S2 observed improperly stored and expired food in multiple refrigerator units which poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/13/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/13/2020
LIC809 (FAS) - (06/04)
Page: 6 of 6