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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601140
Report Date: 05/08/2024
Date Signed: 05/08/2024 01:49:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231218104902
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: 79DATE:
05/08/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator - Ricardo AbanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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- Staff did not notify the fire department of a death at the facility in a timely manner
INVESTIGATION FINDINGS:
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On 05/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigaiton visit in order to deliver the findings for the above allegation. LPA met wtih the administrator Ricardo Aban and explained the purpose of today's visit.

During the investigation period it was found that S1 and S2 went to check on R1 between 530am and 6am and R1 was alert and they cared for R1 and by the time they finished caring for R1, R1's eyes were closed, but did not appear to be asleep. R1 appeared stiff and not moving. S3 was contacted via text and called at 619am from S2 who infomred that R1 was non-responsive. S4 instructed them to call 911. S3 informed 911 dispatcher that the resident had been non-responsive for an hour, factoring in the time S1 and S2 met with R1 to provide care, the time it took to provide the care, the time they took to notify S4, and when S3 called and spoke with 911 dispatcher. S4 stated that staff should have call 911 instead of calling him/her first. This allegation is substantiated.

Based on LPA interviews and items, and letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reviewed with administrator and a copy of this report is provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20231218104902

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:
05/08/2024
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator - Ricardo AbanTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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9
- Questionable death of a resident in care.
INVESTIGATION FINDINGS:
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On 05/08/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigaiton visit in order to deliver the findings for the above allegation. LPA met wtih the administrator Ricardo Aban and explained the purpose of today's visit.

During the investigation period it was found that the death certificate of R1 lists pre-exsisting health conditions such as dementia, alzheimers, and tumor of the lungs as the immediate cuases of R1's death. There were other significant other contributing health factors as well including cancer and diabetes. Caregiver S3 and S1 both confirmed that R1 had his/her oxygen cannula in place after passing. Redwood City Police Department found no evidence of foul play, such as suspicious bruising or marks on R1's body or pillow, nor signs of saliva or blood on the pillow. R1's death appears to be natural with no idication of external interference or wrongdoing. This allegation is unfounded.

This agency has investigated the complaint alleging: Quesionable death of a resident in care. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with administrator and a copy of this report is provided.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20231218104902
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/09/2024
Section Cited
CCR
87465(a)(2)
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87465 Incidental Medical and Dental Care - (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (2) The licensee shall provide assistance in meeting necessary medical and dental needs. This includes transportation which may be limited to the nearest available medical or dental facility which will meet the resident's need. In providing transportation the licensee shall do so directly or make arrangements for this service. This requirement has not been met as evidenced by:
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Facility shall develop a plan of correction (POC) to ensure compliance with Sec.87465(a)(1). Facility will develop a plan to address meeting the resident's medical attention in a timely manner without delay. That plan will be received in CCLD to address deficiency.
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Based on the investigation conducted, caregivers S1, S2, and S3 did not seek timely medical attention for R1. S1, S2, and S3 did not call 911 immediately but sought advice from S4 on what to do in this situation. 911 was alerted approximatley after 1 hour after R1 was found unresponsive. Timely medical attention was not sought in a timely manner.
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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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3