415600927-2-9-2021-14-AS-KHOS-BY3SFP-20210209125034

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 01/08/2021
Date Signed: 02/09/2021 12:49:26 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 CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	WYCKOFF, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(415) 806-4069
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 24	DATE:	01/08/2021
		UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Ricardo Aban		TIME 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 1/8/2021 at 2:30pm. 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 Community Care Licensing Adult and Senior Care (CCL ASCP) to provide technical assistance including staffing support, onsite visits, daily phone calls and tele-visits.
Continued on 9099 C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021

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 2

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: 01/08/2021

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 2