079201030-4-13-2023-15-AS-KHOS-CRFQKP-20230502121439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 04/13/2023
Date Signed: 04/13/2023 02:53:30 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
09/09/2022 and conducted by Evaluator Carol Fowler

COMPLAINT CONTROL NUMBER: 15-AS-20220909150527

FACILITY NAME:	A&A HEALTH SERVICES SAN PABLO		FACILITY NUMBER:	079201030
ADMINISTRATOR:	DOMINICI, ANDREW		FACILITY TYPE:	735
ADDRESS:	13956 SAN PABLO AVE		TELEPHONE:	(510) 609-4040
CITY:	SAN PABLO	STATE: CA	ZIP CODE:	94806
CAPACITY:	225	CENSUS: 12	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	ELEINA RIDOLIF, EXECUTIVE DIRECTOR		TIME COMPLETED:	02:55 PM

ALLEGATION(S):

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Resident was involved in an altercation with other residents due to lack of supervision

Resident fell resulting in a hospital visit

INVESTIGATION FINDINGS:

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On 04/13/2023 at 2:15PM, Licensing Program Analyst (LPA), C. Fowler arrived unannounced to deliver complaint findings for the allegations above. LPA met with Executive Director, Eleina Ridolif and explained the reason for the visit.

During the course of the investigation the Department interviewed 3 staff, 1 witness and Reporting Party (RP); and obtained & reviewed the following documents: Facility & staff roster, incident reports, Physicians report, preplacement appraisal, after visit summary report, MAR, case manager contact information.

Resident was involved in an altercation with other residents due to lack of supervision

While the RP stated that RP spoke with C1 and C1 reported that C1 was attacked by a client at the facility. RP does not have a date, name or details of what happened.

CONTINUE ON LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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-20220909150527

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: 04/13/2023

NARRATIVE

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CONTINUE FROM LIC 9099

RP stated C1 fell and had to go to the hospital, RP is unsure of a date and has no details. During an interview with W1 it was revealed that falling to the ground is one of C1 behaviors. W1 also stated C1 has been placed in a smaller facility with a different level of care. S2 stated that S2 has witnessed C1 fall to the floor and C1 has never been attacked.

During record review LPA received and reviewed several serious incident reports stating C1 fell had hospital visits and sustained injuries. S1 stated C1 would just drop C1 to the ground and S1 doesn’t remember a time that C1 was attacked. S3 stated that C1 would lay on the ground and later report that he was attacked, stated that the facility has cameras in the common areas and could see that C1 was laying on the floor at C1 own will, therefore the allegation above is Unsubstantiated.

Resident fell resulting in a hospital visit

RP stated that C1 fell which resulted in a hospital visit. Record review revealed that C1 fell on several occasions and visited the hospital for treatment. W1 stated that falling to the ground is one of C1’s behaviors, therefore the allegation above is Unsubstantiated.

Based upon records review, interviews conducted, and observations made, the Department has investigated the above allegations and found that they are Unsubstantiated. A finding that the complaint allegation/s are Unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of this report provided

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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