079201030-8-22-2023-15-AS-KHOS-CV5KHR-20230828075534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 07/07/2023
Date Signed: 08/22/2023 01:57:45 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
12/07/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20221207130651

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	DOMINICI, ANDREW		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(510) 609-4040
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 128	DATE:	07/07/2023
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Melissa Billeci, Associate Executive Director		TIME COMPLETED:	11:18 AM

ALLEGATION(S):

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• Facility did not ensure client is provided a safe environment when a client was raped by another client
• Facility did not allow clients to choose their own primary care doctor.
• Facility did not ensure that assistance is provided to the clients in meeting their medical and dental needs
• Facility did not provide/assist clients with transportation for medical/dental appointments
• Facility did not send unusual incident reports to CCL
• Facility improperly evicted a client- No eviction notice given
• Clients do not have direct access to facility telephone
• Clients do not have direct access to laundry room
• Facility did not ensure that clients are given the opportunity to attend and participate in Community events
• Facility failed to assess clients need for personal assistance and care
Client packages need to be opened with a staff present
• Facility did not ensure that beds are comfortable
• Facility does not have a plan in place when clients come back to facility under influence of drugs

INVESTIGATION FINDINGS:

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This is an amendment to the original report dated 07/07/23. A new final 9099 generated on 08/22/23. On 08/22/23 at 1PM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit and met with associate executive director (AED) to deliver amended findings of above allegations. LPA explained the purpose of the visit with AED.

On 07/7/2023, at 11:00AM, 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, Social Worker, and explained the reason for the visit. Licensee, Betty Dominici arrived at approximately 11:35AM. During the course of the investigation the Department interviewed 2 staff, 4 clients and Reporting Party (RP); and obtained & reviewed the following documents: Facility & staff roster, incident reports, Physicians report, preplacement appraisal, after visit summary report, MAR, case manager contact information, police report, activities calendar.
Continue on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

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 5

Control Number 15-AS-20221207130651

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 did not ensure client is provided a safe environment when a client was raped by another client

RP reported that there was a client on client rape. Both clients are no longer living at the facility LPA was unable to interview clients. LPA interviewed S1 who reported that the facility is unaware of a client on client rape, however there was a case that involved a conrep client that had sex. Conrep clients are not allowed to have sexual relationships, if Conrep clients have sexual relationships they will be returned to jail. There was a Conrep client that had sex and was afraid of being returned to jail and reported that Conrep client was raped and wanted to go to the hospital, Conrep client no longer living at the facility. S2 had no knowledge of a rape. Therefore, this allegation is UNSUBSTANTIATED.

• Facility did not allow clients to choose their own primary care doctor.

RP reported that clients are not allowed to choose their own primary care doctor. S1 stated that the facility has two in house doctors all clients are assigned to, clients have the right to choose a primary care doctor of their choice, clients need to get the approval of their conservator or social worker. Interview with C2 revealed that C2 has a primary doctor at the VA hospital, the VA picks C2 up for appointments. Interview with C4 revealed that C4 has no problem with the in-house doctor. Interview with C7 revealed that C7 has an in-house doctor and has no problem being treated by the in-house doctor. Interview with C4 revealed that C4 is being treated by the in-house doctor and is happy not to have to go out to a doctor’s office or hospital. Therefore, this allegation is UNSUBSTANTIATED.

• Facility did not ensure that assistance is provided to the clients in meeting their medical and dental needs

RP reported that clients do not receive proper medical and dental care such as mammogram, podiatrist, dental. Interview with S1 revealed that facility has two in house doctors and vans for transportation to medical facilities up to 25 miles. If clients need to go further than 25 miles for an appointment the facility will schedule transportation, facility has 2 vans for transportation. Interview with C3 revealed that the facility transported C3 to Planned parenthood for an appointment. Therefore, this allegation is UNSUBSTANTIATED.

Continue on LIC9099C

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)

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Control Number 15-AS-20221207130651

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 LIC9099C
• Facility did not provide/assist clients with transportation for medical/dental appointments

RP reported that clients are not provided transportation to medical and dental appointments. Interview with S1 revealed that the facility has 2 vans for transportation to medical/dental appointments and activities. Interview with C3 revealed that the facility transported C3 to a scheduled appointment. Therefore, this allegation is UNSUBSTANTIATED.

• Facility did not send unusual incident reports to CCL

RP reported that the facility was not sending Serious Incident Reports (SIRs). Interview with S1 revealed that facility has been sending SIRs. LPA collected copies of SIRs from S1. Therefore, this allegation is UNSUBSTANTIATED.

• Facility improperly evicted a client- No eviction notice given

RP reported that a client was evicted without an eviction notice. Interview with S1 revealed that C9 was not evicted from the facility. S2 stated that C9 was not evicted from the facility. Record review revealed that C9 was not evicted from the facility. Therefore, this allegation is UNSUBSTANTIATED.

• Clients do not have direct access to facility telephone

RP reported that clients do not have access to the facility telephone. Interview and tour of facility with S1 revealed that there are phones located in the activity room, security desk, med tech rooms that are accessible to clients. Therefore, this allegation is UNSUBSTANTIATED.

• Clients do not have direct access to laundry room

RP reported that clients don’t have access to the laundry room. Interview with S1 and tour of the facility revealed that the laundry room is accessible and available for clients. Interviews with C2 completes C2 own laundry when laundry needs to be done. C3 revealed that C3 completes C3 own laundry, C3 will let staff know when C3 is ready to do laundry. C4 completes C4 laundry when needed. Therefore, this allegation is UNSUBSTANTIATED.
Continue on LIC9099C2

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: 3 of 5

Control Number 15-AS-20221207130651

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 LIC9099C2
• Facility did not ensure that clients are given the opportunity to attend and participate in Community events
RP reported that clients are not given opportunity to attend community events. Interview with S1 revealed that clients are able to attend outside activities and transportation will be provided. Clients are to notify facility that they would like to attend an event and schedule transportation. Facility transports clients to shopping, church, doctor/dental appointments and events requested. Interview with C2 stated that C2 has no desire to attend any events. C3 stated C3 had transportation to doctors appointments and shopping. C4 has been restricted from going out because of drug use, but when able to go out uses transportation. C7 stated that C7 is not interested in going out on outings. Therefore, this allegation is UNSUBSTANTIATED.

• Facility failed to assess clients need for personal assistance and care
RP reported facility failed to assist clients with personal care. Interview with S1 revealed that residents have not requested assistance with personal care such as showering. During record review it was revealed that clients do not need assistance with personal care and there were no doctor orders for assistance for personal care. Interviews with C2 personal care is not needed. C3 stated that no personal care needed. C4 stated that personal care is not needed. C7 stated that personal care is not needed. Therefore, this allegation is UNSUBSTANTIATED.

• Client packages need to be opened with a staff present
RP reported that clients’ packages need to be opened with a staff present. LPA interviewed random clients (C2, C4, C7) during visit. C2 stated that C2 received a package and C2 was called to the office to pick up the package, C2 took the package and opened it in C2 room. C4 stated that when C4 receives mail it’s not opened and C4 was not required to open the mail in front of staff. C7 stated that C7 is not receiving mail or packages at the facility. LPA C. Fowler also asked the administrator if mail or packages are required to be opened in front of staff. Administrator informed LPA packages are given to clients unopened; clients are not required to open packages in front of staff. Therefore, this allegation is UNSUBSTANTIATED.

• Facility did not ensure that beds are comfortable
RP reported that beds are not comfortable. Tour of facility revealed that facility mattresses are adequate. Interviews with C2 revealed that C2 bed is alright and sort of relaxing. C3 stated that C3 bed is comfortable. C4 stated that mattress is good. C7 stated that C7 bed is fine. Therefore, this allegation is UNSUBSTANTIATED.

Continue on LIC9099C3

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221207130651

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 LIC9099C3

• Facility does not have a plan in place when clients come back to facility under influence of drugs

RP reported that facility has no plan in place for clients returning to the facility under the influence of drugs. Interview with S1 revealed that if a client returned to the facility under the influence of drugs the facility would transport them to the hospital to get medical clearance. Record review (house rules) revealed that a client retuning back to the facility will be brought to the emergency room to receive medical clearance if they are off their baseline. The facility will then contact client’s conservator for further instructions. Interview with C3 revealed that C3 came back to the facility after being out in the community using drugs. C3 stated that her conservator was contacted and C3 attended a counseling appointment. 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)

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