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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601140
Report Date: 08/30/2024
Date Signed: 08/30/2024 10:04:09 AM


Document Has Been Signed on 08/30/2024 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066



FACILITY NAME:HOPKINS MANORFACILITY NUMBER:
415601140
ADMINISTRATOR:RICARDO ABANFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVETELEPHONE:
(510) 390-8078
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: 81DATE:
08/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Susan Roquel, HR ManagerTIME COMPLETED:
10:15 AM
NARRATIVE
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On August 30, 2024, Licensing Program Analysts(LPA) John Calandra arrived at the facility at 8:30 AM to conduct a Case Management visit in response to a complaint investigation visit conducted on August 15, 2024. LPA Calandra was greeted by Susan Roquel, HR Manager and explained the purpose of the visit.

During the visit on August 15, 2024, LPA Calandra learned that the incident had not been reported to Licensing. LPA Calandra explained Community Care Licensing's reporting requirements to Ricardo Aban on August 15, 2024.

A Type B violation is being provided today, August 30, 2024, for not reporting the incident.

An exit interview was conducted. This report was reviewed with Susan Roquel, HR Manager and a copy of the report along with Appeal Rights left at the facility.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
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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Document Has Been Signed on 08/30/2024 10:04 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
FACILITY NUMBER: 415601140

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87211(a)(1)(D)

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CCR 87211(a)(1)(D) Reporting Requirements: (a) Each licensee shall furnish to the licensing agency such reports as the Department..A written report shall be submitted to the licensing agency within seven days of the occurrence.
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Licensee/Administrator to submit proof of correction and a written plan outlining how this violation will be avoided in the future to licensing office by due date.
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This requirement is not met as evidenced by an interview with Ricardo Aban, Executive Director, in 2 out of 2 incidents, which was not reported to Licensing, which poses a potential health/safety risk to persons in care.
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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: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2024
LIC809 (FAS) - (06/04)
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