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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:25:54 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 29DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Ricardo AbanTIME COMPLETED:
03:30 PM
NARRATIVE
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On this day at 1200, Licensing Program Analyst (LPA) Jaime Vado and Komal Charitra conducted an unannounced infection control annual inspection. LPAs met with administrator Ricardo Aban and Martha Estalino and explained purpose of today's inspection. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is warm and comfortable, and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available. First-aid kit is inspected and is complete. A Disaster and Mass Casualty Plan is observed. Residents are observed during today's visit. Staff is observed on all floors wearing masks. Food supplies are also observed as not in place. Two day perishable and one week non-perishable food supplies are observed as not in place. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed. Administrator certificate is viewed as current expiring 03/25/2023. Mitigation plan is reviewed and remains current.

The following updated forms are requested to be submitted to CCLD by 09/17/2021:

• Administrator Certificate
• LIC 308 Designation of Administrative Responsibility
• LIC 309 Administrative Organization
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan


Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with Ricardo.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOPKINS MANOR PACIFIC CORPORATION
FACILITY NUMBER: 415600927
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)
Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
Deficient Practice Statement
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This regulation has not been met as evidenced by: LPAs observed both the two day persihable food supply and one week non-perishable food supply as not in place. LPAs observed perishable supply as the low only having one large bag of carrots, two large bag of carrots, one large container of grapes, one box each of peaches and nectarines, and two large bags of celery. This is not adequate to meet the needs of 29 residents in care.
POC Due Date: 09/11/2021
Plan of Correction
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.8755(b)(26). Facility will develop a plan to order more food supplies weekly rather than shopping daily for perishable supplies. Proof of increased food supply orders and photos to show food supplies in place are requested to clear POC. Plan to be received by COB 09/13/2021
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2021
LIC809 (FAS) - (06/04)
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