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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:06:29 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
12/06/2024 and conducted by Evaluator Alicia Delmundo
COMPLAINT CONTROL NUMBER: 15-AS-20241206133113
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: 111DATE:
12/12/2024
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Care Director (CD) Heather PayneTIME COMPLETED:
04:10 PM
ALLEGATION(S):
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Staff verbally abuse client (C1).
INVESTIGATION FINDINGS:
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On this day, 12/12/24, at 12:15 p.m., Licensing Program Analyst (LPA) Delmundo arrived unannounced to investigate the above allegation. LPA met with Care Director (CD) Heather Payne and spoke with Chief Compliance Officer (CCO) Rajdeep Thandi on the phone and informed the purpose of the visit. CCO gave permission to have CD sign and receive this report.

During the course of investigation, LPA obtained copies of C1's LIC602 Physician's Report, Progress Notes and Unusual Incident Reports (UIRs). LPA interviewed the reporting party (RP), clients (C1, C2, C3 and C4) and staff (S1, S3, S4, S5 and CD). LPA also obtained copies current resident roster and clients discharge and admission lists for 01/2024 and 10/2024, and staff schedule for 1/2024, 10/2024 and 12/2024.


.....continued on next page (LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
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-20241206133113
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: 12/12/2024
NARRATIVE
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RP stated that C1 reported that facility staff (S1 and S2) verbally attacked C1; however, C1 did not provide the last name of these 2 staff.

LPA interviewed C1 who stated that a female staff screamed at C1 but was not able to provide the name of this staff. LPA tried to get information about the incident which involved S1 and the date and place of the incident provided by C1 were inconsistent with the information provided to RP. The other 3 clients stated no staff member including S1 verbally abuse them or other clients.

All 5 staff denied being verbally aggressive to C1 and other clients, and stated there's no staff with the name of that of S2. LPA reviewed LIC500 Personnel Report, staff schedules and staff roster which showed no staff with S2's name.

Based on interviews and records review and due to inconsistency of information provided by C1, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is closed as unsubstantiated.

No deficiency cited.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2