079201030-9-17-2025-15-AS-BFOG-DNY7VD-20251201205943

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 09/17/2025
Date Signed: 09/17/2025 04:20:08 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
09/10/2025 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20250910143809

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	RIDOLFI, ELEINA L		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(510) 609-4040
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 132	DATE:	09/17/2025
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Community Care Coordinator Kristi Komori		TIME COMPLETED:	04:35 PM

ALLEGATION(S):

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Facility elevator buttons are unsafe.
Staff do not ensure the facility is kept in clean, safe, sanitary conditions at all times for residents in care.
Facility failed to provide clean bed linens and blankets.
Facility did not provide hygiene care to resident.
Resident sustained unexplained injuries while in care.
Staff did not ensure adequate furnitire is provided for resident's room.

INVESTIGATION FINDINGS:

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On 09/17/2024 at 01:45 PM, Licensing Program Analysts (LPAs) Carol Fowler and David Doidge arrived unannounced to deliver complaint findings for the allegations above. Upon arrival, LPAs met with Community Care Coordinator Kristi Komori and explained the reason for the visit.

During the course of the investigation, the Department conducted interviews with staff, reporting party and witnesses. The Department obtained and reviewed the facility & staff roster, current Physician’s Reports, After Visit Summaries, Care/Case Notes, Medication Administration Records (MAR), and Centrally Stored Medication lists for August and September.

Allegation: Facility elevator buttons are unsafe.
Investigation Finding: Unsubstantiated

W1 reported to the department that the elevator button are in disrepair. LPAs observed that the elevator buttons were being repaired during LPA visit on 09/16/2025. Interview with staff revealed that the elevator button were in disrepair as of Saturday morning 09/13/2025, and was repair 09/16/2025. Therefore this allegation is unsubstantiated.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

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 4

Control Number 15-AS-20250910143809

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: 09/17/2025

NARRATIVE

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Continued from LIC9099

Allegation: Staff do not ensure the facility is kept in clean, safe, sanitary conditions at all times for residents in care.
Investigation Findings: Unsubstantiated.

W1 reported that C1’s carpet was soaking wet, bed had no linens, there was mold and mildew all over the walls, and no furniture. S1 reported to LPAs that C1 will run the shower and sink then get into bed leaving the water running thus flooding the room. Housekeeping regularly cleans rooms twice a week, as reported by staff. S2 stated that C1 turns on sink and leaves it on flooding the room daily. C1 did not have a roommate. S2 changed C1’s room from 205 to 230 due to the wet carpet from flooding. Interview with C1 revealed that C1 brushes teeth and will leave the water running. C1 also stated, C1 no longer leaves the water running as it costs C1 money. C1 also stated that other people would come into C1’s room and throw feces on walls that caused the mold and mildew. Therefore the allegation is unsubstantiated.

Allegation: Facility failed to provide clean bed linens and blankets.
Investigation Findings: Unsubstantiated.

W1 reported that C1 did not have linens on bed nor furniture in room. C1 stated that someone came into room and put feces in bed under mattress cover and on top of blankets. So they were removed and staff provided with new linens. S2 stated that C1 takes linens off bed. Staff assists clients in washing bedding once a week. S1 stated that the facility provides linen if clients run out, and clients can get new linens. LPAs toured facility and saw that he facility has a supply of linens such as mattress covers, sheets, blankets and comforters. Therefore the allegation is unsubstantiated.

Continued on LIC9099C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 15-AS-20250910143809

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: 09/17/2025

NARRATIVE

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Continued from LIC9099C

Allegation: Facility did not provide hygiene care to resident.
Investigation Findings: Unsubstantiated

W1 reported to the department that the facility does not provide hygiene care to residents. C1 stated that the facility provides hygiene supplies, but prefers to buy own. C1 stated that C1 showers every three days. LPAs observed the facility does supply hygiene supplies and clean restrooms for residents to use at will. Therefore the allegation is unsubstantiated.

Allegation: Resident sustained unexplained injuries while in care.
Investigation Findings: Unsubstantiated

W1 reported to the department that C1 has facial injuries. LPAs observed scabs on C1 face. C1 stated that others always tell C1 that C1 is scratching C1’s face, however C1 does not know where scratched come form. Stated had a gopher in purse that may have caused scratches. S1 stated that C1 was seen by facility doctor that prescribed a cream for face. Therefore the allegation is unsubstantiated.

Allegation: Staff did not ensure adequate furniture is provided for resident's room.
Investigation Findings: Unsubstantiated.

W1 reported to the department that C1’s room was not furnished. S2 informed LPAs that C1 had a room change due to flooding of previous room. LPAs toured new room observing adequate furnishings. Therefore the allegation is unsubstantiated.

Continued on LIC9099C

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20250910143809

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: 09/17/2025

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	Continued from LIC9099C Based on the Department’s investigation, the preponderance of evidence standard has not been met; therefore, the above allegations are found to be UNSUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4