079201030-9-28-2023-15-AS-KHOS-CW9JUL-20231003072142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 09/28/2023
Date Signed: 09/28/2023 01:13:35 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
05/17/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230517160540

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	RIDOLFI, ELEINA L		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(510) 609-4040
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 125	DATE:	09/28/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Raj Thandi, Program Director Kayla Sardenga, Resident Care Director		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility staff mismanaged resident's medications resulting in resident's hospitalization
Facility staff do not effectively communicate with resident's medical provider

INVESTIGATION FINDINGS:

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On 09/28/23 at 10AM, Licensing Program Analyst (LPA) D Panlilio conducted a subsequent visit, met with resident care director (RCD) and spoke with program director (PD) on the phone who authorized RCD to act on her behalf and sign the reports. LPA explained the purpose of the visit with PD and RCD. LPA gathered information and delivered investigation findings to PD & RCD.

Allegation: Facility staff mismanaged resident’s medications resulting in resident’s hospitalization
Investigation Finding: Unsubstantiated
During investigation, the department obtained the following documents from administrator - staff roster, clients’ face sheets, admission agreements, physicians reports, clients’ roster, ID/Emergency information, centrally stored medication logs, Medication administration records, Progress notes, hospital discharge reports.

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: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230517160540

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: 09/28/2023

NARRATIVE

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During investigation, LPA L Holmes interviewed clients (C2, C3, C4, C5) on 05/23/23 who stated that staff assist them daily with taking their prescribed medications as ordered by their primary doctors. Staff also assist them in refilling their medications with their pharmacies. Review of clients' centrally stored medication logs and medication administration records show staff administered clients' medications as prescribed.

On 09/27/23, LPA D Panlilio interviewed staff (S1, S2) who stated client (C1) was verbal, ambulatory and not a fall risk. Staff stated they administered C1’s medications as prescribed by her physician. Review of C1’s centrally stored medication logs and medication administration records from 05/2022 until 01/2023 show staff implemented C1’s doctor’s orders as prescribed. One prescription medication (Lisinopril) was discontinued by staff as instructed by C1’s physician dated 11/10/22. Review of C1’s December 2022 records also show she refused to take all her prescribed medications from staff.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff mismanaged resident’s medications resulting in hospitalization and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff mismanaged resident’s medication resulting in hospitalization is unsubstantiated.

Continued on next page, LIC 9099-C pg 2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230517160540

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: 09/28/2023

NARRATIVE

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Allegation: Facility staff do not effectively communicate with resident’s medical provider.
Investigation Finding: Unsubstantiated
During investigation, LPA interviewed staff (S1, S2) who stated that they timely notified client’s (C1) conservator (POA) and physician whenever C1 had a change of condition or was sent to the hospital for evaluation and treatment (October & November 2022). Review of C1’ s lever of care assessments and progress notes show staff communicated C1’s altered mental state to her POA and primary care physician and held care conferences with them to address her change in condition.

Based on records review, interviews conducted, and observations made, the department has investigated the above allegation that staff do not effectively communicate with resident’s medical provider and found it to be unsubstantiated. A finding that the complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation occurred. Therefore, the allegation that staff do not effectively communicate with resident’s medical provider is unsubstantiated.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE:	DATE: 09/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023

LIC9099 (FAS) - (06/04)

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