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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 08/22/2023
Date Signed: 08/22/2023 02:04:38 PM

Document Has Been Signed on 08/22/2023 02:04 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:
08/22/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:59 PM
MET WITH:Melissa Billeci, Associate Executive DirectorTIME COMPLETED:
02:20 PM
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On 08/22/23, LPA D Panlilio conducted an unannounced case management visit to amend two complaints (AS -20221207130651 & AS-202230406154053). LPA met with associate executive director (AED) and explained the purpose of the visit.

LPA advised AED to destroy original complaints and replace with the amended complaints given to AED on today's date, 08/22/23.

AED agreed to destroy original complaint reports that have been amended today.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Daisy Panlilio
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2023
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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