079201030-5-29-2025-15-AS-BFOG-DP8US6-20251210144949

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 05/29/2025
Date Signed: 05/29/2025 04:38:09 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
05/20/2025 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20250520101021

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: 145	DATE:	05/29/2025
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	HEATHER PAYNE, CLINICAL CARE DIRECTOR		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff harass resident

INVESTIGATION FINDINGS:

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On 05/29/2025 at 10:00AM, Licensing Program Analyst (LPA) Carol Fowler arrived unannounced to conduct a 10 day initial visit and deliver findings for the allegation above. Upon arrival, LPA met with Heather Payne Client Care Director.

During the course of the investigation, the Department conducted interviews with staff, S1 & S2, and clients C1, C2 and C3. The Department obtained and reviewed the facility & staff roster, physicians reports, incident reports, progress notes, ID and Emergency form, Personal Rights Agreement form. Requested copies of the police reports via email.

continue on LIC 9099

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

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 3

Control Number 15-AS-20250520101021

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: 05/29/2025

NARRATIVE

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continued from LIC 9099A

Allegation: Staff harass resident
Investigation Finding: UNSUBSTANTIATED

Interview with C1 revealed that C1 felt that staff has been harassing C1, C1 had acquired S1 personal cell phone number and was treating to pass out S1 personal cell phone number and email address to other clients in the facility if C1s complaints were not addressed. C1 stated that C1 went down the street from the facility and the security would not open the gate for C1 to get out of the facility or to get back in the facility and C1 had to climb the gate out and back in upon C1s return, C1 stated that the facility informed C1 that C1 had self discharged C1 out of the facility and then informed C1 that C1 was trespassing. C1 has been posting hand made flyers with S1 personal cell phone number and email address on the walls and doors of the facility. Staff informed C1 that C1 is not able to post signs on the walls and doors, with S1s personal cell phone number. Interview with S1 revealed that C1 has been calling and threatening S1 that C1 would be posting S1 personal cell phone number and email address if C1 complaints have not been taken care of. C1 was posting hand made flyers on the walls and doors at the facility and the facility called the San Pablo Police Department, the Police Department came and talked with C1 and informed C1 that C1 is not able to post the hand made posters. C1 stated that C1 was harassed because C1 was in bed sleeping when the Police came to C1s room. Interview with C2 revealed that C2 has not been harassed nor seen any other clients being harassed by staff at the facility. Interview with C3 revealed that C3 has not been harassed nor seen any other clients being harassed by staff. Interview with S2 revealed that S2 contacted C1 about C1s complaints which were taken care of, except one completing and having the facility Doctor sign the documents which the facility has no control over. S2 stated that C1 left the facility and said C1 is not coming back C1 doesn't need the facility, C1 would not wait for C1s medication and C1 hopped the gate and returned to the facility the same day a few hours later and walked passed staff saying C1 didn't self discharge, Police was called and informed facility that it was a landlord tenant situation. Interview with W1 revealed that W1 just oversees C1 care while living at the facility and is not able to help C1 with completing documents. W1 stated that W1 and W1s manager had a meeting with C1 today and C1 expressed that C1 wants to continue to live at the facility.

continued on LIC 9099 C2

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20250520101021

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: 05/29/2025

NARRATIVE

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Continued form LIC 9099C

Interviews with staff, witness, and clients, review of documents revealed that staff has not harassed C1 and C1 complaints have been addressed. Therefore this allegation is UNSUBSTANTIATED.

Based on interviews and records review, there is not a preponderance of evidence to prove the alleged violation occurred; therefore, the allegation is closed as unsubstantiated.

No deficiency cited.

Exit interview conducted and a copy of this report provided.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/29/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/29/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 3