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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201030
Report Date: 10/15/2024
Date Signed: 10/15/2024 02:17:23 PM

Document Has Been Signed on 10/15/2024 02:17 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: 118DATE:
10/15/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:00 PM
MET WITH:Heather Payne, Care DirectorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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On 10/15/24 at 1:47PM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to open a 10 initial complaint on an unrelated matter and conducted a case management death. LPA met with Heather Payne, Care Director, and explained the purpose of the visit.

On 10/10/24, LPA received an LIC624A regrading the death of Client 1 (C1). LPA reviewed C1’s files, interviewed Heather Payne, Care Director and requested and received documentation including but not limited to relevant incidents that may have occurred prior to C1’s death, case notes, most recent Physician’s Report/Medical Assessment, Medication List, ID/Emergency contact information and requested. Official Death Certificate to be submitted by 11/08/2024.

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: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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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