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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 02/23/2023
Date Signed: 02/23/2023 12:51:27 PM

Document Has Been Signed on 02/23/2023 12:51 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:RIDOLFI, ELEINA LFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 225CENSUS: 133DATE:
02/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Deshun Vines, StaffTIME COMPLETED:
01:00 PM
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On 02/23/2023 at 10:50AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with staff, Deshun Vines and explained the purpose of the visit. Administrator Andrew Dominici arrived at approximately 11:10AM. The facility’s fire clearance was approved for 225.

During the Infection Control Inspection, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas and kitchen. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Cough/sneeze etiquette, social distancing and hand washing posters were observed. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has a mitigation plan and maintains record of routine screening for residents and staff.
Fire extinguishers were last serviced on 07/12/2023.


Continue on LIC809C
Bennett Fong
Carol Fowler
DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/23/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 02/23/2023
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Continue from LIC809

Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 03/02/2023:

LIC 500 Personnel Report
LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 400 Affidavit Regarding Client/Resident Cash Resources
LIC 402 Surety Bond
LIC 610E Emergency Disaster Plan


No deficiencies were cited during this inspection.
SUPERVISOR'S NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC809 (FAS) - (06/04)
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