079201030-4-5-2023-15-AS-KHOS-CR7JQZ-20230424071559

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 04/05/2023
Date Signed: 04/05/2023 02:05:04 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
03/30/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230330104011

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: 117	DATE:	04/05/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	DeShun Vines Interim ED		TIME COMPLETED:	02:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not pick up the facility telephone

Staff mishandles a client's personal funds

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 04/05/2023 at 9:40am, Licensing Program Analyst (LPA), C. Fowler arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with DeShun Vines Interim ED and explained the reason for the visit. Betty Dominici Licensee arrived at approximately 10:50am.

ALLEGATION: Staff do not pick up the facility telephone
Investigation finding: UNSUBSTANTIATED

During the course of the investigation, LPA conducted interviews with S1, S2 and S3 (by phone), LPA C. Fowler called the facility main line before entering the facility and the phone was answered on the 3rd ring. Based on interviews and phone call to the facility the allegation is unsubstantiated.

CONTINUE ON LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

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-20230330104011

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: 04/05/2023

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 LIC9099

ALLEGATION: Staff mishandles a client's personal funds
Investigation finding: UNSUBSTANTIATED

During the course of the investigation, LPA conducted interviews with C1, C2, C3, C4, C5, S1, S2 and S3 (by phone), obtained and reviewed client's safeguarded cash resources LIC405, reviewed funds for C1, C2, C3, C4, and C5. Based on interviews and record review the facility did not mishandle client funds the allegation is unsubstantiated.

Based upon the information obtained during investigation. The above allegation are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted and a copy of report was given

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/05/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2