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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:40:02 PM

Document Has Been Signed on 04/11/2023 12:40 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: 122DATE:
04/11/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:19 PM
MET WITH:Betty Dominici, LicenseeTIME COMPLETED:
01:00 PM
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On 04/11/2023 at 10:00am, Licensing Program Analysts (LPAs), C. Fowler and L. Hall arrived unannounced to conduct a health and safety check as a result of the department receiving a complaint. LPAs met with Licensee, Betty Dominici and explained the reason for the visit.

LPAs observed clients sitting in common area, backyard, dining area and in a meeting being conducted in the activity room.

During the health and safety check, LPAs toured the building with Andrew Dominici including but not limited to kitchen, common areas, bathrooms, bedrooms and outdoor area. Facility is noted to be clean and in good repair and clients in care appear to be safe. There are no imminent health/safety concerns on today's date.

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2023
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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