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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 015601363
Report Date: 04/27/2022
Date Signed: 04/27/2022 03:57:53 PM


Document Has Been Signed on 04/27/2022 03:57 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
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:
04/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Elizabeth Aba, CaregiverTIME COMPLETED:
04:15 PM
NARRATIVE
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On 4/27/2022 starting at 1:30 p.m., Licensing Program Analyst (LPA) Catherine Lin arrived unannounced to conduct Infection Control Inspection. LPA met with staff, Elizabeth Aba and disclosed the purpose of the visit. Administrator Dumitela Dimapilis was out of town and did the televisit with LPA during visit.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and backyard. There is one central entry point for universal screening for staff, residents and visitors. Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff and visitors.

THE FOLLOWING DEFICIENCIES WERE OBSERVED:
· At 1:45 p.m., LPA observed unlocked knife and scissor in kitchen drawer. Staff locked them up during inspection.
· At 2:05 p.m., LPA observed S1 has not completed the health screen including TB test since hiring on 4/11/22.

The above deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations. Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with caregiver. LIC809D, Appeal Rights, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
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 5


Document Has Been Signed on 04/27/2022 03:57 PM - 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
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: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above in 1 out of 3 staff has not completed health screen including TB test since hiring on 4/11/2022 which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/11/2022
Plan of Correction
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Administrator agreed to have staff schedule an appointment for health screen and complete it by the POC due date.

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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 04/27/2022 03:57 PM - 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
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: 04/27/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
87705 Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia
(1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s)

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviewed, the licensee did not comply with the section cited above. LPA observed unlocked knife and scissor in the kitchen drawer which poses an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 04/28/2022
Plan of Correction
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Staff locked up the knife and scissor in the medication cabinet during visit. In addition, Administrator agreed to conduct training with staff of regulation and submit a copy of training agenda and sign-in sheet to CCL by the POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/27/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5