415600927-7-21-2023-14-AS-CSMH-CU2SVA-20230724141225

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 07/21/2023
Date Signed: 07/21/2023 02:41:35 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
06/29/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230629162107

FACILITY NAME:	HOPKINS MANOR PACIFIC CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	WU, LULIN		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 71	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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- Staff do not provide a safe environment for residents
- Staff did not seek medical attention for resident

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the allegations received. LPA met with administrator Ricardo Aban and explained the purpose of this visit.

During the course of the investigation LPA reviewed video footage of the incident that reportedly took place and conducted interviews. In the video footage it was observed that the R1 approached R2 who was sitting at table. R1 placed mug of tea near R2 and geastured and told R2 to leave the chair he/she was sitting in. R1 became aggressive and attempted to remove R2 from the chair physically. R2 picked up the mug and waved it around. In the video the tea was never thrown onto R1 nor did R1 react as if hot tea was thrown on her.

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Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20230629162107

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOPKINS MANOR PACIFIC CORPORATION	FACILITY NUMBER: 415600927
	VISIT DATE: 07/21/2023

NARRATIVE

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Page 2 - LIC9099

Staff checked R1 when he/she complained to staff that hot tea was thrown on her by R2. Med tech checked R1 for any injuries in the areas indicated and did not observe any burns, redness, or even wet clothing. R1 was still in the same clothing and did not change. Staff assessed right away when alerted by R1. This is when the observations were made. There was no need for staff to seek medical attention for R1 due to no injuries being observed. These allegations are unfounded.

This agency has investigated the complaint alleging: Staff do not provide a safe environment for residents and Staff did not seek medical attention for resident. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

No citations issued. Report is reviewed with Ricardo.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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
06/29/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230629162107

FACILITY NAME:	HOPKINS MANOR PACIFIC CORPORATION		FACILITY NUMBER:	415600927
ADMINISTRATOR:	WU, LULIN		FACILITY TYPE:	740
ADDRESS:	1235 HOPKINS AVENUE		TELEPHONE:	(650) 368-5656
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94062
CAPACITY:	88	CENSUS: 71	DATE:	07/21/2023
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

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Staff did not safeguard resident’s personal belongings

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order to deliver the findings regarding the allegations received. LPA met with administrator Ricardo Aban and explained the purpose of this visit.

During the course of the investigation LPA reviewed video footage of the incident that reportedly took place and conducted interviews. During interviews condcuted LPA cannot determine if the allegation took place due to the facts received. Items have been reported as taken or removed that belonged to the resident but LPA cannot prove if these items were removed from the resident's room or was removed from other locations such as a phone charger and slippers of a resident.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20230629162107

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: HOPKINS MANOR PACIFIC CORPORATION	FACILITY NUMBER: 415600927
	VISIT DATE: 07/21/2023

NARRATIVE

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Page 2 - LIC9099

Staff were able to return the slippers intact. Per details received there were holes cut out of the slippers but it was located in the room of the resident. It was just misplaced. The phone charger, it couldn't be determined where it was plugged in as there was a possibility that it was plugged into an area in a public space and may have been removed. To rectify that situation the facility replaced the phone charger free of charge. This allegation is unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

No citations issued. Report is reviewed with Ricardo.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023

LIC9099 (FAS) - (06/04)

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