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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:52:41 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2021 and conducted by Evaluator Lisha Holmes
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210618085850
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:DOMINICI, ANDREWFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(415) 710-7538
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:225CENSUS: 39DATE:
12/09/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Andrew Dominici, Executive DirectorTIME COMPLETED:
02:50 PM
ALLEGATION(S):
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Staff does not adequately supervise residents in care.

Staff are mishandling resident's money.

Facility does not provide a safe environment for resident.

Facility does not allow resident to call the police.

INVESTIGATION FINDINGS:
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12/09/2021 Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Y. Flores-Larios arrived to deliver findings on the above allegations. At 10:30 AM upon arrival LPA and LPM met with Emily Rowley - Associate Executive Director (AED) and informed her of the purpose of the visit. Betty Dominici - Licensee and Andrew Dominici - Executive Director (ED), arrived about an hour later. Raj Ghandi, Chief Compliance Officer was also present throughout the visit.

On 06/28/2021 Licensing Program Analyst (LPA) A.O'Hollaren conducted intterviews and collected documents related to the complaint. A subsequent visit was made on 12/09/2021 to conduct additional interviews.

Report continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20210618085850
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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&A HEALTH SERVICES SAN PABLO
FACILITY NUMBER: 079201030
VISIT DATE: 12/09/2021
NARRATIVE
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After PNI audit was conducted there was no discrepancies in the records, Interviews and record reviews revealed that client's are mostly independent requiring medication management, LPA and LPM observed common area with a phone that is available 24 hours a day for client's use. The majority of the clients have their own cells phones. The facility has procedures in place in the event of altercations and conducts hourly checks on clients throughout the day and night.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED,

Exit interview conducted and a copy of this report provided..
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2