015601363-1-20-2023-15-AS-LFII-CN9UTR-20230120145224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 015601363
Report Date: 01/20/2023
Date Signed: 01/20/2023 02:52:33 PM

Document Has Been Signed on 01/20/2023 02:52 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 SENIORS		FACILITY NUMBER:	015601363
ADMINISTRATOR:	DUMITELA DIMAPILIS		FACILITY TYPE:	740
ADDRESS:	32852 CLEAR LAKE STREET		TELEPHONE:	(510) 487-8758
CITY:	FREMONT	STATE: CA	ZIP CODE:	94555
CAPACITY:	6	CENSUS: 6	DATE:	01/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	ADMINISTRATOR- DUMITELA DIMAPILIS		TIME COMPLETED:	03:10 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 1/20/2023 at 1:00 PM, Licensing Program Analyst (LPA) L. Fici arrived unannounced to conduct an Annual Infection Control Visit. LPA was greeted by, DUMITELA DIMAPILIS Administrator (ADM) and explained the purpose of todays visit. During the inspection, LPA toured facility including but not limited to front entrance, kitchen, common areas, hand washing stations, bedrooms, bathrooms, and backyard. LPA observed COVID-19 signage throughout the facility. Hand washing signs were posted at hand washing stations. LPA observed paper supplies and PPEs are sufficient. Facility has a sufficient 2-day perishable and 7-days non-perishable food supply. All sharps and toxins were locked up and inaccessible to residents in care. Common areas are disinfected frequently throughout the day. Water temperature is measured at 112.5 Degrees F in common area bathroom. Fire extinguisher was last serviced on 11/28/2022. Facilities room temperature is maintained at 68 Degrees F. First aid kit is complete. Carbon monoxide and smoke detectors are functional. Facility passages inside and out are free of obstruction and does not pose a health and safety risk for persons in care. During record review, LPA observed facility has a copy of their Infection Control Plan and Disaster Plan on file. Continue on Lic809.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

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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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
	VISIT DATE: 01/20/2023

NARRATIVE

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Continued from Lic809-C

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties.

1. At 1:15PM, LPA observed S1 is not associated to the facility and needs a transfer request in order to work on the premises. S1 was asked to leave the facility by ADM until further notice.

A $500.00 civil penalty is being assessed for todays visit.

Exit interview conducted with ADM, appeal rights given along with a copy of this report.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 01/20/2023 02:52 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: 01/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(2)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above by allowing S1 to work in the facility without a tranfer request which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/21/2023
	Plan of Correction
1 2 3 4	Licensee agrees to make sure all staff members are associated to the facility prior to working. S1 was asked to leave the premises until further and to return when S1 is associated to the facility. Deficiency cleared

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Liridon Fici	TELEPHONE: (510) 359-0768
LICENSING EVALUATOR SIGNATURE:	DATE: 01/20/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/20/2023

LIC809 (FAS) - (06/04)

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