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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 05/29/2024
Date Signed: 05/29/2024 01:41:50 PM

Substantiated


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
05/23/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20240523140124
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: 123DATE:
05/29/2024
UNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Kayla Sardenga, Operations ManagerTIME COMPLETED:
02:10 PM
ALLEGATION(S):
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Staff did not ensure facility was free from pests
INVESTIGATION FINDINGS:
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On 5/29/2024 at 12:10PM, Licensing Program Analysts (LPAs) Carol Fowler and Tonica Syess-Gibson arrived unannounced to open and deliver complaint findings for the allegation above. Upon arrival, LPAs met with Operations Manager, Kayla Sardenga and explained to her the reason for the visit.

During the course of the investigation, the Department conducted a tour, interviews with staff members, and reporting party. The Department obtained and reviewed the facility & staff roster, and Clark Pest Control report.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
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 3
Control Number 15-AS-20240523140124
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: 05/29/2024
NARRATIVE
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Continue from LIC9099

Allegation: Staff did not ensure facility was free from pests.

Investigation Finding: Substantiated

RP reported that the facility did not ensure facility was free from pests.

During tour and interviews it was revealed that room #217 and #222 was treated for Bed Bugs by Clark Pest Control on May 24, 2024.



During tour of kitchen area gnats were present, interviews with staff revealed that there was a leaky pipe capped off which could be the source of the gnat problem along with a odor and floor damage.

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.

Therefore, this allegation is Substantiated.

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: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20240523140124
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: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2024
Section Cited
CCR
80087(a)(1)
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(1) The licensee shall take keep the facility free of flies and other insects. (a) The facility shall be clean, safe, ... of clients, employees and visitors.
This requirement is not met as evidenced by:
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Administrator agreed to have drains and pipes cleaned, floor repaired and odor eliminated, and submit a copy of the invoice and photos to CCLD by the POC date.
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Based on observation, the licensee did not comply with the section cited above in having gnats. flying around kitchen, on kitchen counter and box of bread which poses a potential health, safety or personal rights risk to persons 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: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3