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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:18:59 PM

Document Has Been Signed on 06/27/2024 04:18 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/
DIRECTOR:		RIDOLFI, ELEINA LFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY: 225CENSUS: 136DATE:
06/27/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:40 PM
MET WITH:Kayla Sardenga, Operations Manager.TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 06/27/2024 at 02:40 PM Licensing Program Analyst (LPA), L. Holmes arrived unannounced to conduct a case management for a health and safety check as a result of CCLD receiving an Unusual/Incident Report (UIR) for an incident on or around 06/21/2024. LPA met with Kayla Sardenga, Operations Manager.

LPA requested file records for C1 and C2: Admission Agreement with house rules, current Physician's Report, Behavioral Assessment, Incident reports, Case Notes, Medication Logs, and Emergency and Identification Information.

LPA requested Resident Roster, LIC 500, Police Report, Sign In/Sign Out sheet for 06/21/24.

LPA toured facility including but not limited to the common areas, bathrooms, kitchen, bedrooms and backyard and garden. Hot water temperature in the shared bathroom measured at 106.4 degrees Fahrenheit (F.). There were 2-days of non-perishables and 7-days of perishable food supplies. Medications were kept locked in the medication room. Smoke and carbon monoxide detectors are combined and observed throughout the facility and the bedrooms. No accessible bodies of water were observed. Fire extinguisher last inspected 01/19/2024. Indoor and outdoor passageways were free of obstruction (construction and repairs of the flooring were in progress near the elevators and front office/conference rooms). Fire extinguisher last inspected 01/19/2024.

No deficiencies are cited on this date.

Exit interview conducted. A copy of this report provided to Kayla Sardenga, Operations Manager.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Lisha Holmes
LICENSING EVALUATOR SIGNATURE: DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/27/2024
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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