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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 03/01/2024
Date Signed: 03/01/2024 01:31:40 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
02/22/2024 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20240222142412
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: 116DATE:
03/01/2024
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Kasi Jones, Operations Manager
Raj Thandi, Administrator		TIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff did not give medications as precribed
INVESTIGATION FINDINGS:
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On 03/01/24 at 11AM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit and met with staff (S1) and spoke with administrator (ADM) on the phone who authorized S1 to act on her behalf and sign the reports. LPA explained the purpose of the visit with staff (S1, ADM), conducted interviews, gathered information and delivered the investigation finding to ADM, S1.

At 12PM, LPA interviewed staff (ADM, S1) and obtained the following information: Personnel record, Client roster, Client’s (C1) admission agreement, physician’s report, Needs & Services plan, Appraisals, Doctor’s orders, Face Sheet, Progress Notes, Centrally stored medication logs, Medical administration records, incident 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: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
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-20240222142412
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: 03/01/2024
NARRATIVE
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Allegation: Staff did not give medications as prescribed
Investigation Finding: Unsubstantiated
During investigation, LPA confirmed with staff (ADM, S1) that client (C1) refused taking her prescribed medications on 08/24/23, 09/13/23 and 09/14/23. Staff also confirmed with LPA that client's conservator was timely informed of C1's medication refusals. Staff stated they continued to provide crisis interventions/conference meetings with C1's responsible parties and family member for resolution. LPA reviewed C1's medication administration records (MARs) dated 01/01/23 until 09/14/23 which showed staff properly administered and recorded C1's daily prescribed and over the counter medications as ordered by her primary care physician. Prior LPA interviews with other clients (C2, C3) on 06/03/23 showed that staff assists clients with their prescribed medications daily. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not give medications as prescribed is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not give medications as prescribed is unsubstantiated.

No deficiencies observed 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: 03/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2