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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:57:29 PM

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
08/02/2022 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20220802134736
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:DOMINICI, ANDREWFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:225CENSUS: 123DATE:
01/13/2023
UNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Nofo Afoa, Resident Service DirectorTIME COMPLETED:
04:06 PM
ALLEGATION(S):
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Illegal eviction
INVESTIGATION FINDINGS:
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On 1/13/2023 at 3:00PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to deliver findings in regards to the allegations above. LPA met with RSD, Nofo Afoa and informed her the reason for the visit.

During the course of investigation, LPA C. Fowler interviewed 2 staff and 1 witness. LPA obtained and reviewed admission agreement, preplacement appraisal form, physician's report, emergency information, unusual incident/injury reports, A&A Health Services resident incident reports and progress notes.

On the allegation illegal eviction: W1 stated C1 was not able to return to the facility due to behavior issues, C1 needed a higher level of care. S2 stated she was told by W1 that C1 needs a higher level of care and would not be returning to the facility. S2 spoke with Contra Costa Regional Medical Center and informed them C1 had been discharged from the facility due to behavior issues and C1 needing a higher level of care. S2 stated that when the County informs the facility that a resident will not be returning to the facility they are not able to accept that client back. S2 stated that the eviction process was never started for C1.

(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 15-AS-20220802134736
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: 01/13/2023
NARRATIVE
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(Continue from 9099)

A&A HEALTH SERVICES COMPLAINT WRITE UP 34736
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted. A copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2