415600927-9-21-2023-14-AS-KHOS-CVZKM8-20230925080107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 09/21/2023
Date Signed: 09/21/2023 02:26:37 PM

Unsubstantiated

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
08/30/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230830163743

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:	09/21/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Ricardo Aban		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

- Resident sustained multiple injuries while in care

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver findings in regards to the allegation. LPA Vado met wtih administrator Ricardo Aban and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, reviewed documents pertaining to R1, and made observations of R1. It was observed that R1 does have self mobility on his/her own in using the wheel chair. R1 was observed moving his/her wheelchair on their own in a common area adjacent to the front of the facility and has the ability to stand himself/herself up form the wheel chair. Discussed was interventions put in place and the facility is attempting to assist in the aid and recovery of the injuries. On this day LPA observed the injured areas of R1 and both areas are now healed. LPA also reviewed on this day a record of R1 skin being assessed by facility on 08/25/2023. Although the injuries took place LPA cannot confirm that the injuries were solely at the fault of the facility. 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.

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: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3