415600927-11-20-2020-14-AS-ABOE-BVK2YY-20201120164932

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/20/2020
Date Signed: 11/20/2020 04:49:59 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 CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	WYCKOFF, TRAVIS		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 26	DATE:	11/20/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Travis Wyckoff Licensee/Administrator		TIME COMPLETED:	04:00 PM

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

On November 20, 2020, Regional Manager Krystall Moore, Licensing Program Manager (LPM) Liza King, Program Analyst (LPA) Ashley Boothe, and Department of Public Health HEFN Rebekah Bird-Wohlgemuth conducted an announced case management visit via Microsoft Teams at 2pm. The team met with Travis Wyckoff Licensee/Administrator and Ricardo A. Aban Executive Director 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. Travis confirmed Resident one has scheduled appointment with psychiatrist on Monday. Resident two is still at the hospital and his case management team is discussing new placement as the board and care There currently are six residents on hospice, three are monitored daily during calls due to their unstable condition. One resident had a change of condition and was up eating and drinking.

The RO requested Travis reach out to LHD to confirm guidance on visitation at this time. Genie was not available via phone or email and Travis will provide an update to the RO as further recommendations are received. At this time Travis stated no requests have been made for residents to leave the facility for the holiday. RO will follow up on daily calls.

Staff screening process in the Mitigation Plan states:

There will be always a designated staff member assigned to do the screening of staff, residents, and visitors, who must strictly comply with public health guidelines and recommendations, which include screening:
a. All staff entering the building. staff must do the following procedures:
i. Must always wear a face covering either N-95 mask or surgical mask only.
ii. Let assigned staff take their temperature
iii. Answer questions about symptoms and potential exposure (COVID-19 questionnaires), sign in with date and time.
iv. Must sanitize hands before and after touching any objects (pen, paper, folder, or any surface).

v. Must report immediately to supervisor or Administrator present if feeling any symptoms and must not come in or remove himself from the building.

b. All visitors entering the facility must do the same procedure as the staff (follow steps above).

Continued on 809 C.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

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: 11/20/2020

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

Continued from 809.

Based on the documentation observed it appears that staff are self screening. Travis stated he will start enforcing staff to sign off on the left side of the screening log.

LPA provided ideas for planning isolation quarters on floors one, two and three in alignment with CDPH guidance for including point of entry and exit, staff break room, and staff restroom. Travis stated he will consider them as he drafts a isolation plan of action and facility sketch due to the RO 11/23/2020.

Travis stated the following Med Tec staff schedules: Staff one works Sunday to Friday 5p-9p, Staff two works Monday to Friday 7a-5p, and Staff three works 7a-5p Saturday and Sunday. Travis stated Staff three prepares medications for the 10 residents who receive bedtime medications and sometimes stays later to pass them. PRN's given at night by NOC shift who has access to the med room. RO requested proof of yearly 8 hour training for all Med Tecs for the last three years be sent to RO by 11/23/2020. RO also requested proof of independent pharmancy consultant reviews by 11/23/2020.

RO requested an independent Infection Preventionist complete CDC training courses other than previously planned shared role of Executive Director. Travis stated that there is a staff on site that completed courses yesterday that will fulfill the role. Staff is an RN, part of the temporary management groups contract, and will be associated to remain on site to fulfill the role after the temporary management contact is concluded. Travis will send proof of training to RO by 11/21/2020.

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 King	TELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley Boothe	TELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:	DATE: 11/20/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/20/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2