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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 05:53:20 PM


Document Has Been Signed on 01/31/2024 05:53 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:
01/31/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:00 PM
MET WITH:Dumitela DimapilisTIME COMPLETED:
06:15 PM
NARRATIVE
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While at the facility reviewing records for the annual inspection, LPA observed Resident 4 (R4) discharge papers dated 7/3/23 indicates R4 developed pressure injury of sacral region stage 3, on 7/16/23 R4 developed decubitus ulcer of sacral region, stage 3 and pressure injury of left perineal ischial region, stage 3 and 1/22/24 indicate R4 with Pressure injury of sacral region, stage 3. R4 is currently in the hospital. The Administrator states there is no home health nurse following up on R4 as of this time.

Based on interview conducted by LPA with the Home Health nurse who provided care to R4 in July, R4 was admitted to home health for treatment of stage 3 wound on 7/4/2023 and got discharged on 8/25/23 because the wound healed.

A $500.00 immediate civil penalty is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview was conducted with the Administrator. Appeal Rights was provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (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 2


Document Has Been Signed on 01/31/2024 05:53 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/31/2024
Section Cited
CCR
87466

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87466 Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. This requirement is not met ase evidenced by:
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A Non compliance conference (NCC) will be scheduled to address plans of correction.
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R4's discharge paper dated 7/16/23 indicates R4 developed stage 3 pressure injury of left perineal ischial region. R4 was admitted back to the facility without home health nurse following up.
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Type A
01/31/2024
Section Cited
CCR87615(a)

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87615 Prohibited Health Conditions
a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:

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A Non Compliance Conference (NCC) will be sheduled to address concerns.
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R4 developed stage 3 pressure injury and was admitted back to the facility without an approved exception which poses an immediate risk to health and safety of clients under 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: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa FontanillaTELEPHONE: (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 2