415600927-2-8-2021-14-AS-ABOE-BY36MW-20210208195636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 02/08/2021
Date Signed: 02/08/2021 07:57:09 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:	02/08/2021
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	02:00 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 8, 2021, Licensing Program Analyst (LPA) Ashley Boothe and Licensing Program Manager (LPM) Liza King conducted an announced case management visit via Teams at 1pm with Infection Preventionist Ricardo Aban. Census 26. At this time Ricardo stated they are anticipating 22 of 26 residents and 23 of 30 staff to have the second dose of COVID vaccine by 2/19/2021. Ricardo stated no incidents for residents in the past few days. Resident one (R1) has stayed in her room and Ricardo stated they are going back to the original spot in the Red Zone to store PPE, keeping Red Zone common area clean. Ricardo stated there is one potential new admission, no move in date at this time. Observed exterior of facility including patio and garden. Observed hand washing, signs, wipes for visitor use on patio. Signs posted to encourage social distancing and disinfection throughout the area. The exterior was observed clean and in good repair. LPA recommended putting a sanitizing station outside for residents and staff use while on smoking breaks. Observed Staff one (S1) moving chairs 6 feet apart and S1 stated she reminds staff during stand up meetings to keep social distancing. Floor One observed where 4 residents reside. Laundry room was clean, laundry was not observed on the floor. Ricardo stated extra supplies of PPE and Zep are in Room 30. Chemicals were locked and properly stored in a cabinet in the laundry room. Shared restroom observed with hand washing sign, soap, paper towels, and touchless covered trash can. At 1:30 observed broken toilet paper holder broken off the wall and Ricardo stated Travis is replacing a new one today. Room 29 observed with February Activity Calendar on the wall. Staff break area observed with social distancing signs posted and chairs spaced apart, wipes on the tables, and x’s on the tables for social distancing. At 1:38 observed exit door by room 30 locked with working alarm turned off. Ricardo stated the locksmith was working on the storage room closet and Travis turned it off to not disturb the residents. Ricardo immediately turned it on and tested the door for a working alarm.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

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: 02/08/2021

NARRATIVE

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Continued from 809.

Floor two observed where 14 residents reside. Room 32 observed two residents napping with wheelchairs accessible to them, February activity calendar posted. Shared staff restroom observed with hand washing sign, soap, paper towels, and touchless covered trash can. Room 15 observed with private bathroom with hand washing sign, soap, paper towels, and touchless covered trash can. Observed exit door between rooms 12 and 14 and exit door between rooms 15 and medications room locked with working alarms turned on.

LPA requested medication audits for the dates of 2/1/2021 and 2/6/2021 for record review.

Floor three observed where 8 residents reside 3 of which are in the Red Zone. Observed Red Zone entrance partitioned between rooms 3 and 5 with a wall mounted hand sanitizer and all COVID precaution signs posted. Staff break room observed and staff was mopping restroom. Restroom observed with hand washing sign, soap, paper towels, and touchless covered trash can. Cleaning supplies and extra PPE supplies were stored in the locked closet. Residents' bedroom doors were all observed to be closed with signs posted of when residents start and stop isolation. Observed PPE station fully stocked with gowns, N95, face shields, shoe covers and gloves. An inventory list was observed in use and Ricardo stated he uses the burn rate calculator for PPE inventory. Sanitizer and all PPE guidance postings were immediately available for staff use. Observed exit door between rooms 17 and 18 locked with a working alarm turned on.

An exit interview was conducted with Ricardo. A copy of this report and appeal rights 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: 02/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2021

LIC809 (FAS) - (06/04)

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