079201030-4-5-2023-15-AS-BFOG-CRY5UF-20230518201548

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 04/05/2023
Date Signed: 04/05/2023 04:02:19 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
01/03/2023 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20230103143351

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:	02:15 PM
MET WITH:	Betty Dominici, Licensee		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility staff do not ensure that client's hygiene needs are met

Facility staff does not keep the facility free from odor

INVESTIGATION FINDINGS:

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On 04/05/2023 at 2:15pm, Licensing Program Analyst (LPA), C. Fowler arrived unannounced conduct a complaint investigation and to deliver complaint findings for the allegation above. LPA met with Betty Dominici Licensee and explained the reason for the visit.

During the course of the investigation, LPA conducted interviews with staff S1, S2, S3, S4, S5 and S6, and clients RP, C1, C2, C3, and C4 refused to interview. LPA toured 5 client rooms, room numbers 109, 135, 202, 231 and 234. LPA also toured the hygiene supply area with RSD Nofo Afoa. LPA obtained the following documents: Facility roster, staff roster, client face sheet, admission agreement, needs and service plan, progress notes, for residents RP, C1, C2, C3, C4.

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)

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Control Number 15-AS-20230103143351

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

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CONTINUE FROM LIC9099

ALLEGATION: Facility staff do not ensure that client's hygiene needs are met
Investigation finding: UNSUBSTANTIATED

LPA tour of supply room and interviews revealed that the facility is providing clients with the hygiene supplies as needed. Supply room was low on supplies during tour, there were supplies ordered that needed to be picked up by staff, Licensee provided the Department with photos 01/18/2023 supply room was fully stocked.

ALLEGATION: Facility staff does not keep the facility free from odor
Investigation finding: UNSUBSTANTIATED

LPA tour of common areas, apartments 109, 135, 202, 231 and 234 and interviews revealed that the facility common areas were free from odor however apartment 109 had a slight odor, 135 had a strong odor and 202 had a odor. Each apartment has housekeeping service once a week, clients sometimes refuse to have apartments cleaned. Common areas are cleaned multiple times in a day, there are 2 to 3 housekeeper and maintenance staff on duty daily

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)

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