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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601140
Report Date: 09/20/2024
Date Signed: 09/20/2024 11:56:48 AM


Document Has Been Signed on 09/20/2024 11:56 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:
09/20/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:35 AM
MET WITH:Susan Roquel, HR Manager and Ricardo Aban, Executive Director TIME COMPLETED:
12:00 PM
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On September 20, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:35 AM, to conduct a Case Management visit regarding an incident that occurred on August 29, 2024, in which a resident attacked another resident. LPA Calandra was greeted by Susan Roquel, HR Manager and explained the purpose of the visit. Ricardo Aban, Executive Director arrived later during the visit.

LPA Calandra requested and reviewed the following documents:

-LIC 602: Physician's reports for both residents involved
-Most up to date LIC 500: Personnel Summary Report(lists all staff working at the facility and their shifts)
-Staff meeting sign in sheet for latest training post incident
-Dementia Care Plan of Operation

LPA Calandra also interviewed staff. Based on these interviews and review of the facility updated LIC 500, the Dementia Care Plan, etc., LPA found that the facility was following their own policies/procedures and not in violation of Title 22 or the Health and Safety Code.

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Ricardo Aban, Executive Director and a copy of the report left at the facility.
SUPERVISOR'S NAME: Andrea MedlinTELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: John CalandraTELEPHONE: 650-266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2024
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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