079201030-9-30-2025-15-AS-BFOG-DMF5MN-20251013200500

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 09/30/2025
Date Signed: 09/30/2025 01:42:07 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
02/01/2024 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20240201162930

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	RIDOLFI, ELEINA L		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(510) 609-4040
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 134	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	12:15 PM
MET WITH:	KRISTI KOMORI, Client Care Coordinator		TIME COMPLETED:	02:16 PM

ALLEGATION(S):

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Staff did not keep the facility free of illegal drugs
Staff did not follow reporting requirements
Staff did not keep resident's authorized person informed of changes in resident's condition
Staff did not provide medical personal resident's history of drug use

INVESTIGATION FINDINGS:

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On 9/30/2025 at 12:15PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPAs met with Client Care Coordinator, KristI Komori and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, reporting party and witnesses. The Department obtained and reviewed the facility & staff roster, Incident Reports from 11/01/2023 to 2/06/2024, Physician’s Report, Pre-Placement Appraisal, Progress Notes, After Visit Summaries, Medication List, from 11/01/2023 to 2/06/2024, Admission Agreement, Identification and Emergency Information, Face Sheet, and San Pablo Police Department Contact, and case number.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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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Control Number 15-AS-20240201162930

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: 09/30/2025

NARRATIVE

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CONTINUE FROM LIC 9099

Allegation: Staff did not keep the facility free of illegal drugs

Investigation Findings: unsubstantiated

RP reported that the facility did not keep the facility free of illegal drugs. Interview with C1 revealed that C1 can’t remember what happened on that day as C1 often forgets. C1 goes out into the community unassisted and will sometimes go out with staff on walks. C1 stated that C1 has friends at the facility that have offered C1 cigarettes to smoke. C1 also stated C1 doesn’t remember having any behaviors and C1 follows the rules. C1 also stated that C1 does not know C1’s conservator. RP stated that C1 had taken crystal methamphetamine, which was revealed as a result of a urine test that the facility performed per RP requested. RP stated that C1 was smoking in another client’s room with a white substance and the facility was not sure if it was drugs. RP also stated that on January 31^st C1 was seen smoking in the room and the incident report said a smokey room but didn’t say a white substance. LPA attempted several times to contact S2 and S3 but did not receive call back. Record review revealed that the incident report stated that C1 was in another client’s room and the room appeared smokey Therefore, this allegation is unsubstantiated.

Allegation: Staff did not follow reporting requirements

Investigation Finding: unsubstantiated

RP stated that the facility didn’t contact RP about C1’s drug use. Review of incident reports LIC 624, facility resident incident reports shows that the RP was contacted by phone and messages were left. Therefore, this allegation is unsubstantiated.

CONTINUE ON LIC9099C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20240201162930

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: 09/30/2025

NARRATIVE

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CONTINUE FROM LIC9099C

Allegation: Staff did not follow reporting requirements

Investigation Finding: unsubstantiated

Allegation: Staff did not keep resident's authorized person informed of changes in resident's condition

Investigation Finding: unsubstantiated

RP reported that the facility staff didn’t inform RP of C1s change of condition. LPAs record review of Facility Rresident Incident Reports (FRIR), and Unusual Incident reports, LIC624, revealed that the RP was contacted via phone call and messages were left. Therefore, this allegation is unsubstantiated.

Allegation: Staff did not provide medical personnel resident's history of drug use

Investigation Finding: unsubstantiated

RP reported that the facility staff did not inform medical personnel of C1’s history of drug use. LPA obtained C1 Medication Administration Records (MAR) which shows that C1 was receiving medication as prescribed. Therefore, this allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, Therefore the allegations are 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: 09/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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