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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/19/2020
Date Signed: 11/20/2020 03:41:15 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 CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 26DATE:
11/19/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Travis WycoffTIME COMPLETED:
04:00 PM
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On November 19, 2020, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, DSS Nurse Consultant Helen Shi conducted an announced case management visit via Microsoft Teams at 1pm. The team met with Maria Cantoria Temporary Manager and Travis Wyckoff Licensee/Administrator at the facility.

During the TA, the following was confirmed, current census today 26; 21 positives of which 21 have cleared and 5 that are negative. One resident followed on the line list was observed in her room with the door closed and upon entry became increasing agitated and anxious the day before. She was on a televisit with her PCP and a request a virtual conference with her psychiatrist was made but they are only in the office Mondays. There currently are six residents on hospice, three are monitored daily during calls due to their unstable condition. No changes of condition noted for residents noted today.

Continued on 809 C.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 11/19/2020
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Continued from 809.

Proof of correction Fire Maintenance was submitted on 11/19/2020. Floor 2 was observed, staff and residents were all maintaining social distancing and wearing masks. The department has requested an updated facility sketch identifying positive, pending, and negative color coding to identify cohorting according to the Mitigation Plan to be used moving forward if isolation protocols need to be implemented by Monday. Travis stated they will be moving the entrance, reception and screening area, and ED office to the Clinton Street entrance, there was not enough connectivity to view this area. The phone system upgrade meeting had taken place the day prior and there is not an option to install alarms, only cameras and upgrade wifi. Observed Floor 1 laundry area clutter had been removed and properly stored chemicals and trash cans observed. Staff break room observed with disinfecting wipes and chairs moved to encourage social distancing. Staff screening process observed, requested documents send to RO for 11/18 and 11/19. Medication logs reviewed and MAR and Centrally Stored Medications log reviewed, RO requested all documents for resident one. Medical record keeping and pharmacy contract discussed. Follow up will be needed for medical record keeping to accord with Title 22 and Medications Guide. Requested all training documents for medical technicians.

No deficiencies were cited on today’s visit. An exit interview was conducted with Travis. A copy of this report was provided to Travis via email, due to COVID-19 precautionary measures, with a "read receipt" to verify the LIC 809 was received. Travis 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 KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2020
LIC809 (FAS) - (06/04)
Page: 2 of 2