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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 08/11/2021
Date Signed: 08/11/2021 02:13:39 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/06/2021 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20210806163557
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: 26DATE:
08/11/2021
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Travis Wyckoff and Rozz WyckoffTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Facility is in finacial distress
Facility does not have liability insurance
INVESTIGATION FINDINGS:
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On 08/11/2021 at 1045 Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced initial 10 day complaint investigation visit. LPA met with Travis Wyckoff and Rozz Wyckoff. Rozz handles facility fiances. LPA explained purpose of today's visit.

During today's investigation LPA confirmed with both Travis and Rozz that the liabiltiy insurance for the facility is not current due to payment therefore it is not active. Also during today's investigation LPA discussed facility finances with both Travis and Rozz and confirm the facility is financial distress. Specifics were discussed and a copy of facility's August financies are recieved in person during today's. These allegations are substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
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-20210806163557
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/11/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2021
Section Cited
CCR
87211(a)(1)(D)
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Reporting Requirement - Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident.
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87211(a)(1)(D). Facility will provide a plan to show how facility will attempt to remain in operation or provide a "roadmap" on what other faciltiy options are availble in maintaining license or residents in care with an approiate time table identified.
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This requirement has not been met as evidenced by: LPA interviewed bothTravis and Rozz regarding facility finances and confirmed that the facility has been in financial distress for several months and thus confirmed via August finances. This was reported to licensing.
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POC is due by identified due date
Type B
08/20/2021
Section Cited
HSC
15605.69
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License Posting, Insurance, and Abuse Reporting - Maintain proof of general and professional liability insurance in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the aggregate.
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Facility shall develop a plan of correction (POC) to ensure compliance with H&S Code Sec. 1796.42(d). Facitly shall provide proof of current liability insurance.
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This requirement has not been met as evidenced by: LPA interviewed bothTravis and Rozz regarding facility's liability insurance and confirmed that the liabiltiy insurance for the facility is not current due to payment therefore it is not active.
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POC is due by identified due date
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: Brenda ChanTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2