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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600927
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:51:19 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/12/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231012143811
FACILITY NAME:HOPKINS MANOR PACIFIC CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WU, LULINFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 75DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ricardo AbanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff did not treat resident with dignity and respect
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 findings regarding allegations received. LPA met with the administrator and explained the purpose of this visit.

During the course of the investigation LPA conducted interviews, reviewed documents and records, and made observations. It was discovered that S1 did observe S2 laughing during a situation in which R1 received a skin injury. It was confirmed by R1, S1, and S2 that the laughing did happen. The laughing may have been out of "being uncomfortable" by S2 but the laughing did occur. S1 did confirm in interviews that S1 did observe S2 laughing and advised S2 to not laugh. This allegation is 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. Report is reviewed with Ricardo.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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
Control Number 14-AS-20231012143811
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 11/29/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/30/2023
Section Cited
CCR
87468.1
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Personal Rights of Residents in All Facilities - (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1)To be accorded dignity in their personal relationships with staff, residents, and other persons.
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The facility shall ensure that further occurrences of comments in this nature be used against residents or used in the facility. As a result of this discovery the facility will conduct personl rights training.
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This regulation has not been met as evidenced by: During interviews it was discovered that S2 laughed at an uncofortable situation where R1 had a skin injury during care. S1 confirmed that S1 did see the laughing and advised to not laugh. This situation demonstrates that S2 did not accord S1 their dignity in their relationships with staff.
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LPA received evidence of such training being provided to all staff and the staff person in question is no longer employed by the facility. This deficiency is cleared.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
10/12/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231012143811

FACILITY NAME:HOPKINS MANOR PACIFIC CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WU, LULINFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 75DATE:
11/29/2023
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Ricardo AbanTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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- Staff inappropriately harmed resident
- Staff are not responding to residents call button
- Staff are not providing adequate food service to 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 findings regarding allegations received. LPA met with the administrator and explained the purpose of this visit.

During the course of the investigation LPA conducted interviews, reviewed documents and records, and made observations. During interviews contradicting information and situational items may have taken place. LPA could not prove any of the above allegations took place as described. These allegations are 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. Report is reviewed with Ricardo.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
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 3