079201030-5-19-2023-15-AS-KHOS-CTLPRE-20230710113235

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201030
Report Date: 05/19/2023
Date Signed: 05/19/2023 01:59:28 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
02/28/2023 and conducted by Evaluator Carol Fowler

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230228165457

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: 130	DATE:	05/19/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Myesha Hood Admin Assistant		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff mismanaged resident's medication

Staff did not seek medical treatment according to resident's involuntary medication order

INVESTIGATION FINDINGS:

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On 05/19/2023, at 10:30AM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct a complaint investigation visit for the above allegations. LPA met with Admin Assistant, Myesha Hood and explained the reason for the visit. Licensee Andrew Dominici arrived at 12:05PM.

During the visit LPA obtained the following documents: Facility & staff roster, incident reports, Physicians reports, preplacement appraisals, Identification and Emergency forms, court document, face sheet, Physicians fax refusal of medication, and MARs.
***Continue on LIC9099C***

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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-20230228165457

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: 05/19/2023

NARRATIVE

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Continue from LIC9099

ALLEGATION: Staff mismanaged resident's medication
Investigation finding: UNSUBSTANTIATED

During the course of investigation for C1 the Department interviewed 3 staff and attempted to interview RP, LPA left voice mails without return calls. LPA received and reviewed MAR, Progress Notes and Physicians fax refusal of Medication Forms which indicates that the Primary Care Doctor and Responsible Party were notified for the dates of January 4, 1/5, 1/6, 1/7 1/8, 1/10, 1/11, and 1/17, 1/18 1/20 and 1/23. Interviewing with S1 revealed that S1 has weekly meeting with RP and S1 would inform RP that C1 was refusing medications including Clozapine, S1 stated that RP asked if S1 notified the Primary Care Doctor S1 stated yes and there were no further instructions given.
During the course of investigation for C2 the Department interviewed 1 staff, 1 client and attempted to interview RP, LPA left voice mails without return calls. LPA received and reviewed C2's MAR, Progress Notes Physicians Report, Medication Order Sheet and Admission Agreement which revealed that C2 was not prescribed a (PRN) pain medication. Interview with S1 revealed that C2 has never requested pain medication. Interview with C2 revealed that C2 doesn't like to take pain medication C2 stated that he reported that C2 needs C2 sleep medication. C2 also stated that C2 doesn't like to stand in line for C2 medication because of pushing and shoving. C2 is currently receiving his sleep medication.

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Carol Fowler
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230228165457

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: 05/19/2023

NARRATIVE

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Continue from LIC9099(1)

ALLEGATION: Staff did not seek medical treatment according to resident's involuntary medication order
Investigation finding: UNSUBSTANTIATED

During the course of investigation for C1 the Department interviewed 3 staff and attempted to interview RP, LPA left voice mails without return calls. Interview with S1 revealed that S1 and RP were having weekly meetings about C1 and C1 medication refusals, S1 stated that RP asked if facility reported the missed dosages to the doctor and S1 stated yes and no further instructions given. S1 stated that titration should be done by a Physician.

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: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC9099 (FAS) - (06/04)

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