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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601140
Report Date: 02/06/2024
Date Signed: 02/06/2024 12:42:36 PM


Document Has Been Signed on 02/06/2024 12:42 PM - 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:WU, LULINFACILITY TYPE:
740
ADDRESS:1235 HOPKINS AVETELEPHONE:
(510) 390-8078
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94062
CAPACITY:88CENSUS: DATE:
02/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:10 PM
MET WITH:Administrator Ricardo AbanTIME COMPLETED:
12:45 PM
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On 02/06/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit regarding an incident report received on 02/05/2024 and discussed with administrator Ricardo on the same day.

R1 left the facility on 02/04/2024 around 5:00pm but didn't return back to the facility by 7:30pm so the facility began to search the neighborhood by car as the weather was bad due to the storm that hit the area. Staff physically went to the local hospitals, hotels, and the church R1 regularly attended every Sunday. By 10pm R1 had not returned to the facility so the facility filed a missing person report with the police department on the same day. On 02/05/2024 by around 11:00am the police department and coroners office visited the facility and informed them that R1 had passed away near the facility. R1 was struck by a vehicle that did not stop at a crosswalk during the stormy weather and the traffic lights were out due to power outages in the area. The facility did not suffer from a power outage. Staff was able to positively identify that it was R1 per the physical description provided to the facility. Administrator provided LPA with resident documents on this day and discussed the timeline of events and indicated that responsible parties were notified,the Department, including the local Long Term Care Ombudsman as well.

Administrator stated the police department and coroners office did not provide report numbers or death reports to the facility at their time of visit on 02/05/2024 as the death is still under investigation.

Report is reviewed with administrator Ricardo.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2024
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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