<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 01/27/2021
Date Signed: 01/27/2021 02:43:59 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/08/2020 and conducted by Evaluator Ashley Boothe
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20201008102716
FACILITY NAME:HOPKINS MANOR PACIFIC CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(415) 806-4069
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 25DATE:
01/27/2021
UNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Ricardo AbanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee placing residents in danger by failing to adhere to local Public Health’s recommendations to keep residents safe during the outbreak
Residents left in soiled briefs for hours
Facility is not clean
Lack of staff
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ashley Boothe made a subsequent complaint investigation tele visit on 1/27/2021 at 2:15pm to provide update to findings and deficiencies cited from Community Care Licensing Adult and Senior Care (CCL ASCP) the 9099 previously delivered to the facility on 1/8/2021. This report serves to supersede SUBSTANTIATED Complaint Report Allegations opened 10/08/2020. LPA spoke to Ricardo Aban, Infection Preventionalist and explained the purpose of the visit. A physical visit was not conducted in that the Department is not conducting visits due to COVID-19 precautionary measures.

LPA reviewed documents provided by the Investigation Bureau(IB) Report, findings of the IB report, case management reports for unannounced onsite inspection, case management reports from daily and weekly unannounced and announced tele-visits, and conducted interviews to investigate the allegations of the reporting party. On 9/18/2020 staff one which had been working while showing symptoms, tested positive for COVID. The facility was supported by Maestro Medical Testing, California Department of Public Health, Healthcare-Associated Infections program (HAI), San Mateo County Public Health (SMCPH), and CCL ASCP to provide technical assistance including staffing support, onsite visits, daily phone calls and tele-visits.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20201008102716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/27/2021
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
26
27
28
29
30
31
32
On 10/13/2020 interview with Maestro Medication Testing staff stated during observations, none of the recommended changes were made, for example residents were not moved to the “hot zone” on floor three, positive and negative residents on all floors. Staff was observed walking around the building without PPE, no one was supervising. Staff were walking room to room touching everything. CCL ASCP RO Sacramento South, reported that the Licensee demonstrated a lack of follow through, resistance to assistance, and the facility has a significant noncompliance history. Through inspections it was observed staff were not following COVID-19 precaution practices including engaging in social distancing, wearing masks and appropriate PPE, following sanitization and disinfection practices, hand hygiene, and visitor and staff screening procedures to mitigate the spread of COVID. Licensee was observed entering a COVID positive quarantine room without donning additional PPE other than a N95 he was already wearing. Staff stated they were unaware of how many COVID-19 positive residents or how many hospice residents there are. After the implementation of the COVID-19 Mitigation Plan, deficiencies continued to be cited for lack of adherence to the Mitigation Plan. Staffing Shortages without providing appropriate supervision were observed, which resulted in staffing assistance with the placement of a Temporary Manager provided by CCL ASCP. The needs and services of residents’ care plans were not maintained, prior to the Temporary manager, this resulted in the facilities inability to provide an adequate staffing plan. On 10/8/2020 caregivers interviewed stated diapers should be changed three times daily but sometimes outside agencies staff do not show up for coverage. Also reported that about 90% of residents are incontinent. On 10/6/2020 HAI Surveyor and Licensee observed unoccupied rooms with bedding/sheets that had been used by previous resident had not been cleaned since last week, trash bins were halfway full and some full, in the hallways, and no housekeeper was present during the visit. Administrator stated the last time they did laundry was 9/29/2020. A Non Compliance Conference was conducted on 11/17/2020, following repeated citations related to the facilities noncompliance with its Mitigation Plan to reduce the spread of COVID-19. A Ban on Admission to the facility was implemented from 11/23/2020 to 12/29/2020.

Based on inspection, interviews, and records review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Exit interview conducted with Ricardo. Copy of the report sent via e-mail with a "read receipt" to verify the LIC 9009 and appeal rights were received. Ricardo is to print out the report and email signed copies to LPA at ashley.boothe@dss.ca.gov or fax to (916)263-4744.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20201008102716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2021
Section Cited
CCR
87405(d)
1
2
3
4
5
6
7
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.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
This defeciency was previously cited on 11/13/2020 and the POC remains the same.
8
9
10
11
12
13
14
Based on observation, the Licensee demonstrated a lack of follow through and resistance to assistance to COVID-19 precaution practices including engaging in social distancing, wearing masks and appropriate PPE, following sanitization and disinfection practices, hand hygiene, and visitor and staff screening procedures to mitigate the spread of COVID which poses an immediate health and safety risk to residents in care.
8
9
10
11
12
13
14
Type B
02/08/2021
Section Cited
CCR
87303(a)
1
2
3
4
5
6
7
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
This defeciency was previously cited on 11/9/2020 and the POC remains the same.
8
9
10
11
12
13
14
Based on interview, observation and record review the Licensee did not ensure the facility was sanitary by with bedding/sheets that had been used by previous used had not been cleaned, trash bins were full in the hallways, no housekeeper, and Administrator stated the last time they did laundry was last week. This poses a potential risk to residents in care.
8
9
10
11
12
13
14
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: 01/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20201008102716
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/27/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/28/2021
Section Cited
CCR
87464(f)
1
2
3
4
5
6
7
87464(f)
Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidence by:
1
2
3
4
5
6
7
This defeciency was previously cited on 1/15/2021 and the POC remains the same.
8
9
10
11
12
13
14
Based on records review, interview, and observation there were instances of staffing shortages without providing adequate supervision. This poses an immediate health and safety risk to clients in care.
8
9
10
11
12
13
14
Type B
02/08/2021
Section Cited
CCR
87625(b)(3)
1
2
3
4
5
6
7
87625 Managed Incontinence (b) General Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: (3) Ensuring that incontinent residents are kept clean and dry and that the facility remains free of odors from incontinence.
This requirement is not met as evidence by:
1
2
3
4
5
6
7
Licensee agrees to submit a written plan how to maintain compliance with this regulation to LPA by POC due date of 2/8/2021.
8
9
10
11
12
13
14
Based on records review, interview, and observation the Licensee did not provide suffecient staffing to provide incontinent care to residents. This poses an potentail health and safety risk to clients in care.
8
9
10
11
12
13
14
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: 01/27/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 4