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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 07/07/2023
Date Signed: 07/07/2023 12:40:15 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
01/10/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230110153615
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:RIDOLFI, ELEINA LFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:225CENSUS: 128DATE:
07/07/2023
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Shanda Thompson-Williams, Social WorkerTIME COMPLETED:
11:10 AM
ALLEGATION(S):
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Facility does not have sufficient staffing to meet the needs of the clients
Facility does not have a sufficient planned activities for clients
Staff does not ensure all required signs are posted in the facility
INVESTIGATION FINDINGS:
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On 07/7/2023, at 10:45AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings of a complaint investigation for the above allegations. LPA met with Shanda Thompson-Williams, and explained the reason for the visit. Licensee, Betty Dominici arrived at approximately 11:35AM.

During the course of the investigation the Department toured the facility and interviewed 1 staff, and Reporting Party (RP); and obtained & reviewed the following documents: Facility roster, staff roster, staff schedule and activities calendar.
Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
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-20230110153615
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: 07/07/2023
NARRATIVE
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Continue from LIC9099

Facility does not have sufficient staffing to meet the needs of the clients

RP reported that the facility does not have sufficient staff to meet the needs of the clients. Record review showed that there were enough staff on duty for all shifts. Interview with S1 revealed that facility is fully staffed. Therefore, this allegation is UNSUBSTANTIATED.

Facility does not have a sufficient planned activities for clients

RP reported that the facility does not have sufficient planned activities. Record review revealed that the facility has a full calendar everyday during the month. While touring the facility LPA observed a group session. Therefore, this allegation is UNSUBSTANTIATED.

Staff does not ensure all required signs are posted in the facility

RP reported that the facility does not ensure all required signs are posted in the facility. While touring the facility LPA observed all signage throughout the facility. Interview with S1 revealed that signage is posted, however clients will at time rip them down and they are replaced. Therefore, this allegation is UNSUBSTANTIATED.

Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.



Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2