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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 03/13/2024
Date Signed: 03/13/2024 03:21:57 PM

Substantiated


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
12/11/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20231211154743
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: 108DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kayla Sardenga, Operations ManagerTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff did not notify resident's responsible parties of resident's hospitalization.
INVESTIGATION FINDINGS:
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On 3/13/2024 at 2:35PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Operations Manager, Kayla Sardenga and explained to her 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, current Physician’s Reports, After Visit Summaries, Care/Case Notes, Medication Administration Records (MAR), and Centrally Stored Medication lists for August and September.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
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 5
Control Number 15-AS-20231211154743
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: 03/13/2024
NARRATIVE
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Continue from LIC9099

Allegation: Facility staff did not notify resident's responsible parties of resident's hospitalization.
Investigation Finding: Substantiated

RP reported that the facility did not contact RP to report an incident that occurred on 9/18/2024 which resulted in C1 having a short hospital stay. RP stated that Kaiser hospital reached out to W1 when the facility was preparing to discharge C1. A&A Health Service San Pablo was provided a copy of the Power of Attorney via email to S2 and S3 on 9/13/2023. Therefore, this allegation is Substantiated.

Based on the Department’s investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.



Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20231211154743
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2024
Section Cited
CCR
80061(a)(b(g)
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(a) Each licensee or applicant shall furnish to the licensing...
(b) Upon the occurrence, during ... agency's next working day during... containing the information specified in (2) below shall be submitted to the licensing agency within seven days following the occurrence of such event. (f) The items specified in (b)(1)(A) through (H) above shall also be reported to the client's authorized representative, if any.
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Administrator agreed that the facility policy will be updated/developed for all staff to reference and follow for reporting requirements. Administrator shall send a copy of the policy to the department via email by POC date.
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THIS REQUIREMENT IS NOT MET AS EVIDENCED BY:

Administrator failed to report incident to the Power of Attorney.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
12/11/2023 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20231211154743

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: 108DATE:
03/13/2024
UNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:Kayla Sardenga, Operations ManagerTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff did not provide adequate supervision, resulting in resident being left on the floor for an extended period of time after falling.

Facility staff over medicated resident while in care.
INVESTIGATION FINDINGS:
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On 3/13/2024 at 2:35PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to deliver complaint findings for the allegation above. Upon arrival, LPA met with Operations ManagerKayla Sardenga and explained to her 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, current Physician’s Reports, After Visit Summaries, Care/Case Notes, Medication Administration Records (MAR), and Centrally Stored Medication lists for August and September.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20231211154743
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: 03/13/2024
NARRATIVE
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Continue from LIC9099A

Allegation: Facility staff did not provide adequate supervision, resulting in resident being left on the floor for an extended period of time after falling.

Investigation Finding: unsubstantiated

RP reported that the facility did not provide adequate supervision, which resulted in C1 being left on the floor for an extended period of time. S1 stated that the facility conducts room checks each hour and also conduct head counts. S3 stated that S3 noticed C1 had not been coming out of C1 room, S3 stated S3 went to C1’s room to check on C1 and C1 stated to her that C1 was doing okay. Therefore, this allegation is unsubstantiated.

Allegation: Facility staff over medicated resident while in care.


Investigation Finding: unsubstantiated

Rp reported that the facility staff was over medicated resident. LPA obtained C1 Medication Administration Records (MAR) which shows that C1 was receiving medication as prescribed. Therefore, this allegation is unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that staff did not give medications as prescribed is unsubstantiated.

No deficiencies observed during visit.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5