<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 01/21/2026
Date Signed: 01/21/2026 04:22:13 PM

Substantiated


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
01/13/2026 and conducted by Evaluator Carol Fowler
COMPLAINT CONTROL NUMBER: 15-AS-20260113114743
FACILITY NAME:A&A HEALTH SERVICES SAN PABLOFACILITY NUMBER:
079201030
ADMINISTRATOR:RIDOLFI, ELEINA LFACILITY TYPE:
735
ADDRESS:13956 SAN PABLO AVETELEPHONE:
(510) 609-4040
CITY:SAN PABLOSTATE: CAZIP CODE:
94806
CAPACITY:225CENSUS: 129DATE:
01/21/2026
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:KIRISTI KOMORI COMMUNITY CARE COORDINATORTIME COMPLETED:
05:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not properly report incident
Facility staff falsified resident records
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 01/21/2026 at 9:45am, Licensing Program Analyst (LPA), C. Fowler arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Kristi Komori Community Care Coordinator and explained the reason for the visit. Eleina Ridolfi Executive Director arrived a short time after LPAs arrival.

ALLEGATION: Facility staff did not properly report incident
Investigation finding: SUBSTANTIATED

CONTINUE ON LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
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-20260113114743
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: 01/21/2026
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
CONTINUE FROM LIC 9099

During the course of the investigation, LPA conducted interviews with S1, S2, S3 and S4 regarding the facility's AWOL reporting procedures. S1 reported that when a client is AWOL, the incident is first reported to the on-duty security guard, who then notifies the Medication Technicians (MTs). The MT notifies the client's Responsible Party (RP) and files a missing persons report with the San Pablo Police Department within 24 hours. S2 reported that when a client is AWOL, the information is reported to the security guard, who then notifies the MTs. S3 reported that when S3 and other clients returned to the facility, C1 stood on the corner adjacent to the facility but did not enter. S3 stated that C1 informed S3 that C1 was not returning to the facility and indicated that C1 is an adult and able to make decisions. S3 reported this incident to the security guard. S4 reported that when a client is AWOL, the incident is reported to the security guard, who then notifies the MTs. The MT informs the RP and files a missing persons report with the San Pablo Police Department within 24 hours. LPA also conducted a record review which revealed that C1 left the facility on January 9, 2026. The incident was reported to the RP and the San Pablo police Department on January 11, 2026. Therefore, this allegation is SUBSTANTIATED.

ALLEGATION: Facility staff falsified resident records
Investigation finding: SUBSTANTIATED

During the course of the investigation, LPA conducted interviews with S4 regarding the facility's reporting false documents. S4 reported that the facility is required to report when a client misses medications. LPA conducted a record review, which revealed that the facility reported to the RP and the client's physician on January 10, 2026, that C1 had "refused all AM medications". However, records indicate that C1 went AWOL on January 9, 2026, and was not present at the facility to receive medications. Additionally, the facility did not notify the physician until January 11, 2026. S4 reported that an internal investigation would be initiated to determine the cause of the inaccurate reporting. Therefore, this allegation is SUBSTANTIATED.





SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20260113114743
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/21/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2026
Section Cited
CCR
80012
1
2
3
4
5
6
7
False Claims
No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility.
This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Executive Director (ED) has agreed to have all Medication Technicians and ED trained on using the correct verbage when
8
9
10
11
12
13
14
Based on interviews and record review, facility reported false claims of missed medication to C1s doctor and conservator, C1 was AWOL from the facility at the time the false claims of missing medication was reported.
8
9
10
11
12
13
14
reporting, by a CCLD authorized vendor. ED will provide a copy of all attendees certificate by the POC date.
Type B
01/30/2026
Section Cited
CCR
80061(b)(1)(e)
1
2
3
4
5
6
7
(b) Upon the occurrence, during the operation of the ... events specified in (1) below, a report shall be made to the licensing agency within the... he ...specified in (2) below shall be submitted to the licensing agency within ...vent.
(1) Events reported shall include the following:
(E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client.
1
2
3
4
5
6
7
Executive Director (ED) has agreed to have all Medication Technicians and ED trained on using the reporting requirements
8
9
10
11
12
13
14
Based on interviews and record review facility failed to report an AWOL to the RP and Police Department within the 24 hour reporting timeframe.
8
9
10
11
12
13
14
by a CCLD authorized vendor. ED will provide a copy of all attendees certificate by the POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 3