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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 07/06/2022
Date Signed: 08/15/2022 02:44:40 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
05/19/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220519102658
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:DOMINICI, ANDREWFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(415) 710-7538
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:225CENSUS: 95DATE:
07/06/2022
UNANNOUNCEDTIME BEGAN:
03:51 PM
MET WITH:Niare Feaster, Area ManagerTIME COMPLETED:
05:40 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to assist client in obtaining appropriate dental care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 07/06/2022 at 3:30 pm, Licensing Program Analyst (LPA), C. Fowler arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Niare Feaster Area Manager and Betty Dominici and explained the reason for the visit.

During the course of the investigation, LPA conducted interviews with C1, S1, S2 and S3, obtained and reviewed resident’s records. Based on interviews and record review the facility provided appropriate dental care appointments for C1. C1 failed to wait at the emergency room or scheduled dental appointments.

Based upon the information obtained during investigation. The above allegation 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
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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