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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 07/07/2023
Date Signed: 08/22/2023 01:53:29 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
04/06/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230406154053
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:
12:00 PM
MET WITH:Melissa Billeci, Associate Executive DirectorTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility does not ensure all staff have a criminal record clearance
Staff did not ensure bedbug issue was properly treated
Staff dose not ensure bathing assistance is provided to clients in care
Staff yells at clients in care
Facility fire alarm is in disrepair
Staff does not ensure the facility floors and walls are kept in clean, sanitary conditions
Staff physically assaulted resident
INVESTIGATION FINDINGS:
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This is an amendment to the original report dated 07/07/23. A new final 9099 was 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 07/07/2023, at 10:45AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver complaint findings for the above allegations. LPA met with Betty Dominici and explained the reason for the visit. During the course of the investigation the Department interviewed 2 staff, 3 clients and Reporting Party (RP); and obtained & reviewed the following documents: Facility and staff roster, Physicians Report, Admission agreement and Preplacement for C2, C3, C4 and C5. LPA conducted interviews with staff S1 and S2 and 3 clients C1, C2 and C3.
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 6
Control Number 15-AS-20230406154053
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 ensure all staff have a criminal record clearance

RP reported that the facility has staff working that are not fingerprint cleared that are a part of the maintenance crew. Interview with S1revealed that the maintenance worker are contracted staff and not employed by the facility directly. Therefore, this allegation is UNSUBSTANTIATED.

Staff did not ensure bedbug issue was properly treated

RP reported that the facility had a bed bug issue, and it was not treated properly or reported to Community Care Licensing. Record review, tour and Interviews with S1 and S2 revealed that the facility hired Bay Area Bed Bug. Company treated facility where bed bugs were found. The company used heat treatment. Therefore, this allegation is UNSUBSTANTIATED.

Staff dose not ensure bathing assistance is provided to clients in care

RP reported that clients are not getting bathing assistance and clients will not admit that they need assistance but it has been told to RP in conversation that some clients need assistance with showering. Interviews with C1, C2, and C3, record reviews revealed that clients named in complaint do not have doctors’ orders for assistance with showers. C1 stated that C1 doesn’t need assistance with bathing. C2 stated that C2 doesn’t want assistance with showers and C3 stated that C3 doesn’t need assistance with showers. Therefore, this allegation is UNSUBSTANTIATED.

Staff yells at clients in care

RP reported that clients are getting yelled at by staff. Interviews with C1, C2 and C5 revealed that staff has never yelled at clients in care. C2 stated no staff has ever yelled or been mean to C2. C5 stated staff treats C5 nice and has never yelled at C5. Interview with S1 revealed that the facility has 4 clients that are hard of hearing and staff has to speak loud to that client. 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: 2 of 6
Control Number 15-AS-20230406154053
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 fire alarm is in disrepair

RP reported that the facility fire alarm is in disrepair. Interview with S6 and tour of facility and record review revealed that the fire alarm system is operating in the kitchen area which was the area that was reported not working. Johnson Controls Fire Alarm Inspection Report reveals that inspection results passed. Therefore, this allegation is UNSUBSTANTIATED.

Staff does not ensure the facility floors and walls are kept in clean, sanitary conditions

RP reported that the facility and walls are not kept clean. Interview with S6 revealed that the facility has cleaning staff on duty daily. LPA toured the facility, and the facility walls and floors were clean and housekeeping was mopping the floors in the common areas. Therefore, this allegation is UNSUBSTANTIATED.

Staff physically assaulted resident

RP stated that one of the maintenance workers jumped on the back of C1 to break up a fight C1 was having, RP stated that C1 fell to the ground and had a seizure. Interview with S4 revealed that there was a fight with C1 and the maintenance staff helped pull them apart that S4 witnessed towards the end of the fight, S4 stated that C1 fell to the ground, and it seems that C1 had a seizure, paramedics came and check C1 and C1 did not go to the hospital. S4 stated that the facility created and reported the fight to Community Care Licensing. Interview with S5 revealed knows that there was an altercation in the dining room and S5 walked in the dining room when the fight was over and S5 didn’t see anything. Interview with C1 revealed that C1 had a fight about 3 months ago and no on jumped on her back and a maintenance worker picked C1 up off the ground and moved her away. C1 stated that C1 knows what the maintenance staff looks like but doesn’t know staffs name. Therefore, this allegation is UNSUBSTANTIATED.


Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given
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 6
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
04/06/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20230406154053

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:
12:00 PM
MET WITH:Betty Dominici, LicenseeTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Facility floor is in disrepair
INVESTIGATION FINDINGS:
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On 07/07/2023, at 12:15PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver complaint findings for the above allegations. LPA met with Betty Dominici, Licensee and explained the reason for the visit.

During the course of the investigation the Department interviewed 2 staff, 3 clients and Reporting Party (RP); and obtained & reviewed the following documents: Facility and staff roster, Physicians Report, Admission agreement and Preplacement for C2, C3, C4 and C5. LPA conducted interviews with staff S1 and S2 and 3 clients C1, C2 and C3.
Substantiated
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: 4 of 6
Control Number 15-AS-20230406154053
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 floor is in disrepair

RP reported that an area of the floor on the second in the hallway was in disrepair. Tour of the facility revealed that the floor at the end of the hallway was in disrepair. Therefore, this allegation is SUBSTANTIATED.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.



Exit interview conducted. A copy of this report and appeal rights 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: 6 of 6
Control Number 15-AS-20230406154053
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/14/2023
Section Cited
CCR
80087(a)
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Buildings and Grounds. The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients... This requirement is not met as evidence by:
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Administrator has had the floor repaired on 5/19/2023 and provided copies of the repair and an invoice. POC cleared.
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Based on investigation, licensee did not comply with the section cited above by having floor in disrepair which poses a potential health and safety risk to the clients in 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 6