079201030-5-17-2023-15-AS-KHOS-CTLLQ7-20230710085704

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 05/17/2023
Date Signed: 05/17/2023 04:22:00 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
12/13/2022 and conducted by Evaluator Carol Fowler

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221213155040

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: 130	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Betty Dominici Licensee		TIME COMPLETED:	01:28 PM

ALLEGATION(S):

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Staff did not interveen to prevent client from harming other client in care

Staff allowed client to speak inappropriately to other client in care

INVESTIGATION FINDINGS:

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On 05/17/2023, at 1:25PM, Licensing Program Analysts (LPAs) C. Fowler and L. Fontanilla arrived unannounced to continue a complaint investigation visit for the above allegations. LPAs met with Betty Dominici and Andrew Dominici and explained the reason for the visit.

During the course of the investigation the Department interviewed 2 staff, 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 and intake assessment.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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-20221213155040

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: 05/17/2023

NARRATIVE

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Continue from LIC9099

Staff did not intervene to prevent client from harming other client in care

RP was a former client who lived at the facility stated that RP had an altercation and was being bullied and called names by C1 resulted in a fall and hitting RP head. RP stated that staff witnessed the altercation and this would happening on a regular basis. During interview with S1 and S2 it was revealed that RP seeks attention and fabricates stories to get attention. During record review of intake assessment, it reveals that client exhibits attention seeking behaviors, and has history of polysubstance abuse. S2 stated that RP informed S2 that RP was hit and fell to the ground when S2 check it was not witnessed and no incident reported. Therefore the allegation above is Unsubstantiated.

Staff allowed client to speak inappropriately to other client in care

During interview RP stated that clients were being verbally abusive. RP stated that there were 2 staff that would witness the verbal abuse happening but would not intervene. RP could not provide the name of staff members. Therefore the allegation above 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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol Fowler	TELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

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