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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 12/09/2021
Date Signed: 12/09/2021 02:51:01 PM

Document Has Been Signed on 12/09/2021 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:DOMINICI, ANDREWFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(415) 710-7538
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 225CENSUS: 39DATE:
12/09/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Andrew Dominici, Executive Director TIME COMPLETED:
01:30 PM
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12/09/2021 Licensing Program Analyst (LPA) L. Holmes and Licensing Program Manager (LPM) Y. Flores-Larios conducted an unannounced annual inspection. At 10:30 AM upon arrival LPA and LPM met with Emily Rowley - Associate Executive Director (AED) and informed her of the purpose of the visit. Betty Dominici - Licensee and Andrew Dominici - Executive Director (ED), arrived about an hour later. Raj Ghandi, Chief Compliance Officer was also present throughout the visit.

Facility has a completed COVID-19 mitigation plan and submitted it to LPA for Community Care Licensing (CCL).

LPA and LPM inspected the facility inside and out with ED, Licensee and Chief Compliance Officer. LPA and LPM observed a screening station located near the front entrance with a visitor's log, hand sanitizer and thermometer. Routine symptom screening (+/-) temperature and symptom checks are done at entry for all staff and visitors by security. Residents are screened for COVID-19 symptoms, temperatures are checked daily and logged by staff. LPA and LPM observed COVID-19 signs posted in the facility and at the elevators. Trash bins were observed with touchless lids.

In the event of an outbreak, the 2nd and 3rd floor will be used for isolation with individual apartments, there is a staff break room and one dedicated entrance,

Medications are centrally stored in a locked medication room. Centrally stored PPEs were inspected and 3 isolation carts were observed. First aid kit inspected and observed complete with manual located in the medication room.

No deficiencies cited.
Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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