079201030-6-9-2023-15-AS-KHOS-CSYGXJ-20230620054400

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 06/09/2023
Date Signed: 06/09/2023 02:46:09 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
01/31/2022 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20220131135404

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	DOMINICI, ANDREW		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(415) 710-7538
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 121	DATE:	06/09/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Raj Thandi, Administrator Betty Medici, Licensee		TIME COMPLETED:	12:50 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident's medication is mismanaged by staff
Resident was restrained by staff
Staff threatened physical harm to resident
Staff are mismanaging resident funds

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 06/09/23 at 10:30AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with associate executive director (AED) and licensee (LC) to deliver the findings of above allegations. LPA explained the purpose of the visit with AED and LC.

Allegation: Resident medication is mismanaged by staff
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with staff (LC, S1,S4) that client (C1) refused taking his medications from 12/03/21 until 12/09/21. Staff also confirmed with LPA that client (C2) refused to take her medications from 11/19/21 until 11/29/21. LPA reviewed the medication administration records (MARs) dated 11/19/21 – 11/29/21 & 12/03/21 – 12/09/21 of C1 and C2 which showed that both clients refused to take their prescribed medications from staff. Other clients (C4, C5, C6) confirmed with LPA that staff assists them their prescribed medications daily. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that clients’ medication is mismanaged by staff is unsubstantiated. Continued on next page, LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

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-20220131135404

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: 06/09/2023

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
26
27
28
29
30
31
32

Allegation: Resident was restrained by staff
Investigation Finding: Unsubstantiated
During investigation, staff (S2, S3) denied restraining any client (C1) at the facility. Clients (C3, C4, C5) confirmed with LPA that staff always assist them with their activities of daily living (ADLs) and that staff do not use restrains on any client. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident was restrained by staff is unsubstantiated.

Allegation: Staff threatened physical harm to resident

Investigation Finding: Unsubstantiated
During investigation, staff (S2, S3, S4) denied threatening or physically abusing any client at the facility. Clients (C4, C5, C6) confirmed with LPA that staff treat them well and they that they have not witnessed staff yell, threaten or physically abuse any client at the facility. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff threatened physical harm to client is unsubstantiated.

Allegation: Staff are mismanaging resident funds

Investigation Finding: Unsubstantiated
During investigation, LPA observed clients P & I monies were kept locked in the executive office's cabinet. LPA reviewed random clients P & I records (C4, C5, C6). LPA observed P & I monies records matched their physical monies and are kept separate from facility funds. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff are mismanaging resident funds is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 06/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2