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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:03:10 AM


Document Has Been Signed on 09/10/2024 11:03 AM - 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: 134DATE:
09/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Raj Thandi Chief Compliance OfficerTIME COMPLETED:
11:20 AM
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On 09/10/24 at 10:00 AM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to conduct a case management. LPAs met with Raj Thandi, Chief Compliance Officer, and explained the purpose of the visit.

On 05/28/2024, LPA received an LIC624A regrading unwanted sexual contact of Client 1 (C1). LPAs reviewed C1’s and C2's files, requested and received documentation including but not limited to , case notes, residents roster, employee roster, personnel records, admission agreements, emergency and ID information, Medication List, visiting roster for 04/01/2024 to 05/01/2024, physicians' reports, needs and services plans, level of care notes/function assessments and special incident reports. Raj Thandi has informed LPAs that C1 has moved from the facility and C2 was incarcerated, but current location unknown and discharged from the facility.

No deficiencies were cited today.



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: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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