079201030-10-10-2022-15-AS-KHOS-CKANTX-20221017104527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 10/07/2022
Date Signed: 10/10/2022 09:26:39 AM

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
03/09/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220309145345

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	DOMINICI, ANDREW		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(415) 710-7538
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 123	DATE:	10/07/2022
		UNANNOUNCED	TIME BEGAN:	03:29 PM
MET WITH:	Niare Feaster, Executive Director		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility failed to administer medicine to client

Facility lacked supervision to client in care

Facility did not safeguard client's personal belongings

INVESTIGATION FINDINGS:

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On 10/7/2022 at 3:20 PM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegation above. LPA met with Executive Director, Niare Feaster and explained the reason for the visit.

During the course of the investigation, LPA conducted interviews with staff, Responsible Party (RP), obtained and reviewed documents. On the allegation facility failed to administer medicine to client. Staff stated that Client 1 (C1) had a written order to take the medication for 14 days. LPA’s review of medication sheet indicated the last dose for that medication was to be taken on 01/20/2022. Therefore, staff followed doctor’s order on prescription.

On the allegation facility lacked supervision to client in care. It was stated during LPA’s interview with staff and the witness that C1 was transported to a new facility in San Francisco. After C1 exited the van and was in the process of getting the COVID-19 screening inside the new facility C1 decided to leave. Therefore, C1 was no longer under the care and supervision of A&A Health Services San Pablo.
Continue on 9099 C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20220309145345

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: 10/07/2022

NARRATIVE

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Continue from 9099

On the allegation facility did not safeguard client’s personal belongings. During interview with S3 it was stated that C1 carried a black backpack with his personal belongings but S3 was unaware what the backpack contained. S3 also stated that he packed C1 belongings from C1’s room and shipped to RP. During record review LPA observed and reviewed client’s personal property and valuables document which did not list Nintendo switch or games. LPA reviewed an email dated March 4, 2022 from RP to S2 that indicated RP received C1’s suitcase with clothing, Nintendo switch and an apple charger.

Based upon the information obtained during investigation and record reviews. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2022

LIC9099 (FAS) - (06/04)

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