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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601140
Report Date: 06/21/2024
Date Signed: 06/21/2024 10:22:37 AM


Document Has Been Signed on 06/21/2024 10:22 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: 84DATE:
06/21/2024
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Scotts Villa Corp Licensees, Administrator Ricardo Aban, Property owners Wendy and Olive, and Attorney Jake ReinhardtTIME COMPLETED:
10:30 AM
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On 06/21/2024, San Bruno Regional Office conducted a non-compliance conference meeting with licensee members Wendy Wong, Olive Manalastas, Carrie Bautista, and John Lee. Administrator Ricardo Aban and attorney Jake Reinhardt are also in attendance on behalf of the facility. Present in the meeting is Regional Manager, Vivien Helbling, Licensing Program Managers April Cowan, Andrea Medlin, and Licensing Program Analysts, Jaime Vado and Alicia Delmundo.
 
During this non-compliance meeting, the following violation was discussed, Incidental Medical and Dental Care.

Additionally it was discussed that the facility will be cited under 87469(c)(2) - Incidental Medical and Dental Care. The facility staff did not inform 911 of the advance directive for R1 and did not provide emergency services the advance directive information at time of arrival of medical services and the fire department which caused confusion during an emergency situation. This poses an immediate health and safety risk to residents in care.

During this meeting, it was discussed, Licensee will receive more frequent monitoring inspection visits to ensure compliance with this compliance plan and Title 22 Regulations for 2 years. Licensee was provided the link below for resources and guidance to improve facility operations: 
https://www.cdss.ca.gov/inforesources/community-care/resource-guide-for-providers

Deficiencies of the California Code of Regulations, Title, 22 are cited on the attached LIC809D. Additional civil penalties may be assessed
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
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 06/21/2024 10:22 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: 06/21/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/22/2024
Section Cited
CCR
87469(c)(2)

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87469 Advanced Directives and Requests Regarding Resuscitative Measures:(c) If a resident who has an advance directive and/or request regarding resuscitative measures form on file experiences a medical emergency, facility staff shall do one of the following:(2) Immediately give the advance directive and/or request regarding resuscitative measures form to a physician, registered nurse or licensed vocational nurse if the physician or nurse is in the resident’s presence at the time of the emergency and assumes responsibility. This regulation has not been met as evidenced by:
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The licensee shall develop a written plan the facility written plan for staff regarding training on what to do during an emergency, what documents are to be provided to emergency personnel, identify staff who will call 911. Describe staff responsibilities during initiation of 911. Who will provide the advance directive and/or request regarding resuscitative measures form to emergency or medical personnel in the time of an emergency.
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Based on the investigaton interviews it was discovered that the facility staff did not inform 911 of the advance directive for R1 and did not provide emergency services the advance directive information at time of arrival of medical services and the fire department at time of their arrival which caused confusion during an emergency situation. This poses an immediate health and safety risk to residents 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: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 06/21/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/21/2024
LIC809 (FAS) - (06/04)
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