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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
015601363
Report Date:
01/31/2024
Date Signed:
01/31/2024 05:55:31 PM
Document Has Been Signed on
01/31/2024 05:55 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:
01/31/2024
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:40 AM
MET WITH:
Dumitela Dimapilis
TIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Luisa Fontanilla arrived unannounced to conduct annual required inspection and met with Administrator Dumitela Dimapilis. LPA explained to the Administrator the purpose of the visit.
During the visit, LPA inspected the facility inside and out including but not limited to resident rooms, bathrooms, kitchen, dining, garage and backyard. Hot water measured at 115.8 Fahrenheit. There was sufficient supply of perishable and non perishable foods. LPA observed sufficient supply of warm blankets, sheets and towels available for use of the residents. Administrator states two of six residents are in the hospital. Smoke detectors and carbon monoxide were tested and observed functional. First aid kit was observed to be complete.
At around 11:43 am, LPA reviewed 5 resident and 3 staff files. At around 4:00pm, LPA interviewed staff and residents.
The following deficiencies were observed:
1. Physical Plant/Environmental Safety - - Unused bed, recliner, mattress, hoyer lift, cart, ripped screen door in the backyard and refrigerator light out were observed during the inspection.
2. Physical Plant/Environmental Safety - - Bathroom disorganized and smelled urine.
3. Physical Plant/Environmental Safety - Comet unlocked under the sink. Lysol unlocked in the unlocked drawer inside the resident's room.
4. Residents with Special Health Needs - R1 developed stage 3 pressure injury in July 2023 but no reappraisal was conducted.
continuation on Lic 809D
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
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
6
Document Has Been Signed on
01/31/2024 05:55 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:
01/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having Lysol and comet unlocked which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2024
Plan of Correction
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Administrator locked all chemicals during the visit. Deficiency is cleared.
Type A
Section Cited
CCR
87611(d)
General Requirements for Allowable Health Conditions
(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation and record review, the licensee did not comply with the section cited above in not conducting Reappraisal for R1 who developed pressure injury which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/02/2024
Plan of Correction
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Administrator will review Sec 87611 and submit certificate of understanding to CCL by POC 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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
LIC809
(FAS) - (06/04)
Page:
2
of
6
Document Has Been Signed on
01/31/2024 05:55 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:
01/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87616(b)(1)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following: (1) Documentation of the resident's current health condition including updated medical reports, other documentation of the current health, prognosis, and expected duration of condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in not having an approved exception for R1 who developed stage 3 in July 2023 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
02/02/2024
Plan of Correction
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Administrator will review Sec 87616 and submit certificate of understanding to CCL by POC date.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having unlocked insulin in the refrigerator which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
01/31/2024
Plan of Correction
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Administrator locked insulin during the visit. Deficiency is cleared.
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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
LIC809
(FAS) - (06/04)
Page:
3
of
6
Document Has Been Signed on
01/31/2024 05:55 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:
01/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having ripped screen door, unused DMEs in the backyard which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/14/2024
Plan of Correction
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By POC date, Administrator will clear the backyard of unused DMEs and fix screen door and submit photo proof to CCL by POC date.
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in having a bathroom that smells urine and unorganized which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/14/2024
Plan of Correction
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Administrator will get the bathroom cleaned, disinfected and organized and submit photo proof to CCL by POC 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:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
LIC809
(FAS) - (06/04)
Page:
4
of
6
Document Has Been Signed on
01/31/2024 05:55 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:
01/31/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs.
This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, R4 has Alzheimer's Dementia but last Physician's Report is in 2022, the licensee did not comply with section cited which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
02/21/2024
Plan of Correction
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Administrator will schedule R4 for the year's medical assessment and submit a copy to CCL by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
LIC809
(FAS) - (06/04)
Page:
5
of
6
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:
01/31/2024
NARRATIVE
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5. R4 has dementia; last medical assessment was 3/3/2022.
6. Residents with Special Health Needs - Insulin unlocked in the refrigerator was observed during the visit.
Deficiencies are cited per Title 22 California Code of Regulations (refer to Lic 809D).
Exit interview was conducted with Administrator and Appeal Rights was provided.
SUPERVISOR'S NAME:
Yvonne Flores-Larios
TELEPHONE:
(510) 286-0517
LICENSING EVALUATOR NAME:
Luisa Fontanilla
TELEPHONE:
(510) 286-7147
LICENSING EVALUATOR SIGNATURE:
DATE:
01/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
01/31/2024
LIC809
(FAS) - (06/04)
Page:
6
of
6