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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601363
Report Date: 01/29/2021
Date Signed: 01/29/2021 03:34:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:A & P CARE HOME FOR SENIORSFACILITY NUMBER:
015601363
ADMINISTRATOR:DUMITELA DIMAPILISFACILITY TYPE:
740
ADDRESS:32852 CLEAR LAKE STREETTELEPHONE:
(510) 487-8758
CITY:FREMONTSTATE: CAZIP CODE:
94555
CAPACITY:6CENSUS: 6DATE:
01/29/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Dumitela "Ella" Dimapilis, AdministratorTIME COMPLETED:
03:10 PM
NARRATIVE
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On 1/29/2021 at 2:30 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management televisit via Facetime due to shelter in place directed by the Governor. LPA spoke to Administrator, Dumitela “Ella” Dimapilis (S1) and explained the purpose of the televisit.

An investigation conducted by the Department’s Auditor on 10/14/2020 indicated resident (R1) purportedly authorized S1 to write checks on R1’s behalf. Based on the documents received by the Department’s Auditor, S1 was questioned about the transactions that occurred from R1’s account. However, S1 was unable to provide the department copies of receipts. In addition, it was discovered that S1 did not maintain an “adequate accounting system”. Because the facility was handling R1’s cash resource, it was noted by the department that S1 did not obtain requisite surety bond coverage.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.
    Exit interview conducted. Appeal rights and a copy of report will be provided via email.
    SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
    LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
    LICENSING EVALUATOR SIGNATURE:

    		DATE: 01/29/2021
    I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:

    		DATE: 01/29/2021
    This report must be available at Child Care and Group Home facilities for public review for 3 years.
    LIC809 (FAS) - (06/04)
    Page: 1 of 3
    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

    FACILITY EVALUATION REPORT (Cont)    		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
    COMMUNITY CARE LICENSING DIVISION
    CCLD Regional Office, 1515 CLAY STREET, STE. 310
    OAKLAND, CA 94612

    FACILITY NAME: A & P CARE HOME FOR SENIORS
    FACILITY NUMBER: 015601363
    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 01/29/2021
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type B
    02/19/2021
    Section Cited

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    		87217 Safeguards for Resident Cash, Personal Property, and Valuables
    (g) Each licensee shall maintain adequate safeguards and accurate records of cash resources.....(1)Records of residents' cash resources maintained as a drawing account shall include a ledger accounting...(B) An acceptable receipt where purchases are made....
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    		Based on record review, License did not comply with the above regulation by not maintaining an accounting ledger and receipts for R1 which poses a personal rights issues to residents in care.
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    		 Administrator will send the following to CCL no later than 2/19/2021:
    -Self certification letter and training agenda
    -A copy of receipt from county's Public Administrator in the amount of $1,951

    Type B
    02/19/2021
    Section Cited

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    		87216(c) Bonding
    Each application for a license or renewal of license shall be accompanied by an affidavit on a form provided by the licensing agency. The affidavit shall state whether the applicant/licensee will be entrusted/is entrusted to safeguard or control cash resource......
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    		Based on record review, Licensee did not comply with the above regulation by not obtaining a surety bond to entrust Licensee of R1's cash resource which poses a personal rights issues 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: Harpreet HumpalTELEPHONE: (510) 285-3928
    LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
    LICENSING EVALUATOR SIGNATURE:
    		DATE: 01/29/2021
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 01/29/2021
    LIC809 (FAS) - (06/04)
    Page: 2 of 3
    STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

    FACILITY EVALUATION REPORT (Cont)    		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
    COMMUNITY CARE LICENSING DIVISION
    CCLD Regional Office, 1515 CLAY STREET, STE. 310
    OAKLAND, CA 94612

    FACILITY NAME: A & P CARE HOME FOR SENIORS
    FACILITY NUMBER: 015601363
    DEFICIENCY INFORMATION FOR THIS PAGE:
    VISIT DATE: 01/29/2021
    Deficiency Type
    POC Due Date /
    Section Number
    DEFICIENCIES
    PLAN OF CORRECTIONS(POCs)
    Type B
    02/12/2021
    Section Cited

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    		87405(d) Administrator - Qualification and duties
    The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply.
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    		Based on record review and interviews by the Department's Auditor, Licensee did not comply with the above regulation by mishandling R1's finances which poses a personal rights issues 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: Harpreet HumpalTELEPHONE: (510) 285-3928
    LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
    LICENSING EVALUATOR SIGNATURE:
    		DATE: 01/29/2021
    I acknowledge receipt of this form and understand my appeal rights as explained and received.
    FACILITY REPRESENTATIVE SIGNATURE:
    		DATE: 01/29/2021
    LIC809 (FAS) - (06/04)
    Page: 3 of 3