415600927-11-18-2020-14-AS-ABOE-BVGTH2-20201118134402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/18/2020
Date Signed: 11/18/2020 01:45:32 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:	11/18/2020
TYPE OF VISIT:	Case Management - Other	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Travis Wycoff Licensee		TIME COMPLETED:	01:00 PM

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On November 18, 2020, Regional Manager (RM) Krystall Moore, Licensing Program Manager (LPM) Liza King, Licensing Program Analyst (LPA) Ashley Boothe, and Department of Public Health, Health Facilities Nurse Evaluator Rebekah Bird- Wohlgemuth conducted an announced case management visit via Microsoft Teams at 10am. 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 will be discharged from the hospital and has decided to move to another board and care facility at the request of his case manager. Eviction notice was previously sent to the department and the Regional Office requested written confirmation from the case manager and an email sent to the department to confirm the eviction has been rescinded. A resident that had an unwitnessed fall and a change in condition over the past few days, has been moved to her previously occupied room prior to COVID cohorting, on the main floor where she can be more closely observed. One resident followed on the line list was observed in her room with the door closed and upon entry became increasing agitated and anxious. Travis stated a call has been made to her case management team to request a virtual conference with her psychiatrist to address her behaviors and medication management. She does not have access to her TV and a follow up call to her mother will occur today. There currently are six residents on hospice, three are monitored daily during calls due to their unstable condition. The process for updating the line list has been confirmed that the administrators update it morning and night using google drive to ensure team is all aware of current residents’ status.

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: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

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

LIC809 (FAS) - (06/04)

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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: 11/18/2020

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Continued from 809.

Travis stated the Fire Maintenance scheduled for today has been rescheduled at the vendors request to 9:30am on 11/19/2020. Floor 2 was observed, and PPE placement recommendations were made to add an additional PPE station on Floor 2. 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. LPA Boothe observed food stored to be unexpired and provided TA to ensure use by dates were written so staff know how to ensure usage of opened foods. LPA observed chemicals removed from kitchen area. LPA observed the restroom in room 32 to have a new lock and organized personal products in the bathroom cabinet. Travis stated they will be moving the entrance, reception and screening area, and ED office to the Clinton Street entrance. The phone system upgrade meeting is today, and facility upgrades will be discussed for install as early as next week. New ED started today and all documents for association will be sent to the department by close of business 11/18/2020. A LIC 500 including the new ED will be sent to the department.

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: 11/18/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2020

LIC809 (FAS) - (06/04)

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