079201030-10-2-2025-15-AS-BFOG-DN5TL2-20251105134848

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 10/02/2025
Date Signed: 10/02/2025 03:02:11 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
08/28/2025 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20250828101620

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: 138	DATE:	10/02/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Comminity Care Coordinator Kristi Komori		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Resident diagnosed with severe malnutrition while in care.
Resident not provided with incidental medical and dental care.
Facility did not inform conservator of Resident change in condition.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 10/02/2025 at 1:40PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver findings for the allegations above. Upon arrival, LPAs met with Client Care Director Kristi Komori and explained the purpose for the visit..

During the course of the investigation, the LPAs interviewed staf and clients. The following documents were reviewed by LPAs: Resident Roster, Staff Roster, Physician Report, Progress Notes, and medication list.

Allegation: Resident diagnosed with severe malnutrition while in care.

Investigation Finding: Interview with S1 revealed that C1 always comes down and gets lunch and dinner and takes it to C1’s room to eat. S1 also stated that C1 sometimes asks for extra food. Interview with S2 revealed that C1 drinks two Ensure twice a day as witnessed by S2. S2 also stated that C1 get C1’s plate and separates self from others, eats a little bit of food, then takes the rest back to C1’s room. Interview with C1 revealed that C1 likes the food served in the facility, and stated that C1 eats all of C1’s food in C1’s room, but sometimes does not want to eat too much. C1 tries to eat a lot of dinner, but avoids overeating to no gain wight, C1 stated that C1 does not want to be overweight. Interview with W1 revealed that C1 has always been petite and on the small side. W1 stated that C1 eats C1’s meals in C1’s room. Therefore this allegation is unsubstantiated.

Continued on LIC 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

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-20250828101620

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: 10/02/2025

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099

Allegation: Resident not provided with incidental medical and dental care.

Investigation Finding: Interview with S1 revealed that the facility has a dentist and medical doctor that visits the facility twice a month. Clients have the right to see both the doctor and dentist. Interview with W1 revealed that C1 has a hard time trusting people, and has to be motivated to see a medical doctor or dentist. W1 stated that C1’s previous case manager informed W1 that C1 is not going to see a doctor or dentist at the facility. Interview with C1 revealed that C1 saw a dentist a week ago, and the dentist has seen C1 in the past, and there was no issues. C1 stated that C1 needs more dental gum and toxifying toothpaste. C1 stated that C1 brushes C1’s teeth two to three times per week. C1 stated that C1 is able to C1’s food really well and drinks one to two Ensures. Therefore this allegation is unsubstantiated.

Allegation: Facility did not inform conservator of Resident change in condition

Investigation Finding: Interview with S1 revealed that staff report to responsible parties each times there is an incident and it is noted in the progress note and incident reports. Interview W1 revealed that W1 was notified by phone and received an incident report from the facility regarding the incident. Therefore the 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 above are unsubstantiated.

No deficiencies cited 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: 10/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 2