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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:16:06 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
10/10/2024 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20241010151653
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: 118DATE:
10/15/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Heather Payne, Care DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff injected resident with poison
INVESTIGATION FINDINGS:
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On 10/15/24 at 10AM, Licensing Program Analyst (LPA) Carol Fowler conducted an unannounced complaint visit and met with staff (S1) and spoke with Chief Compliance Officer, Rajdeep Thandi on the phone. LPA explained the purpose of the visit with staff (S1, CCO), conducted interviews, gathered information and delivered the investigation finding to Heather Payne, Care Director.

LPA interviewed staff (S1, S2, S3,) and obtained the following information: Personnel record, Client roster, Client’s (C1, C2, & C3) physician’s report, Progress Notes, Medical administration records, and incident reports.


Continued on next page, LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
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-20241010151653
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: 10/15/2024
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Continue from LIC9099

Allegation: Staff injected resident with poison

Investigation Finding: Unsubstantiated

During investigation, LPA confirmed with staff (S1,S2 & S3) that client (C1) refused taking C1 prescribed medications on starting in late September up until present date. 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 for resolution staff also stated that the county conservator is in search of a higher level of care for C1. LPA reviewed C1's medication administration records (MARs) dated 10/01/24 until 10/15/24 which showed staff properly attempted to administer and recorded C1's daily prescribed medications as ordered by C1 primary care physician. C1's Medication Notes shows that C1 has refused all medications for the period of 10/01/2024 to 10/15/2024 morning medications. LPA interviews with other clients (C2, C3) on 10/15/24 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 injected resident with poison is unsubstantiated.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC9099 (FAS) - (06/04)
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