<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600927
Report Date: 11/17/2020
Date Signed: 11/17/2020 03:06:33 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 CORPORATIONFACILITY NUMBER:
415600927
ADMINISTRATOR:WYCKOFF, TRAVISFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVENUETELEPHONE:
(650) 368-5656
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 26DATE:
11/17/2020
TYPE OF VISIT:Case Management - Legal/Non-complianceANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Travis WycoffTIME COMPLETED:
10:30 AM
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
A non-compliance conference was conducted today via tele-visit due to COVID-19 precautionary measures. During today's meeting, the following were present: Regional Managers Krystall Moore (Sacramento South) and Vivien Helbling (San Bruno), Licensing Program Managers (LPM) Liza King and Julio Montes, Licensing Program Analysts Ashley Boothe and Jaime Vado, Licensee/ Administrator Travis Wykoff and Maria Cantoria (Temporary Manager).

The Department still has serious concerns regarding the operation of the agency.

The focus of the concerns at this time area:


· Adherence to COVID-19 Mitigation Plan
· Staffing Shortages
· Medication Management
· Maintenance and Operations
· Personnel Requirements
· Reporting Requirements
· Care of Persons with Dementia
· Personal Rights
· Training
· AWOLs
· Food Service

Continued on 809 C.
SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
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 3
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: 11/17/2020
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.

Deficiencies cited during today's meeting. LPA Boothe and LPA Johnson conducted an unannounced visit on November 13,2020. LPA’s observed PPE Donning and Doffing postings were not posted inside and outside of COVID positive resident rooms or directly above PPE stations. LPA’s observed identification of positive, pending, or negative color-coded signs were not posted on resident rooms as outlined in the Mitigation plan.

Deficiencies were given pursuant to Title 22 rules and regulations, Health and Safety Codes. 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 and 809-D 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.

The case will be referred to the Department's Legal Division. Completing the Non- Compliance Conference does not deprive the Department of its authority to take appropriate formal legal action under the Health and Safety Code if such action is deemed necessary by the Regional Manager.

SUPERVISOR'S NAME: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2020
LIC809 (FAS) - (06/04)
Page: 2 of 3
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/18/2020
Section Cited

1
2
3
4
5
6
7
87468.1 Personal Rights of Residents in All Facilities(a)(2) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

8
9
10
11
12
13
14
This requirement is not met as evidenced by: The facility did not post PPE and COVID identification signs following the facility’s Mitigation Plan. LPA's observed PPE Donning and Doffing postings were not posted inside and outside of COVID positive resident rooms or directly above PPE stations and identification of positive, pending, or negative color-coded signs were not posted on resident rooms which poses an immediate risk to residents in care.

8
9
10
11
12
13
14

1
2
3
4
5
6
7

1
2
3
4
5
6
7
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: Liza KingTELEPHONE: (916) 263-4752
LICENSING EVALUATOR NAME: Ashley BootheTELEPHONE: (916) 708-7751
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2020
LIC809 (FAS) - (06/04)
Page: 3 of 3