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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 06/26/2020
Date Signed: 06/26/2020 02:52:13 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:A & J ASSISTED LIVING FACILITYFACILITY NUMBER:
415601066
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:53CENSUS: 48DATE:
06/26/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Juliet PacaldoTIME COMPLETED:
03:00 PM
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LPA Jeung called facility to conduct a case management visit, but was unable to reach facility by phone, as the "call could not be completed as dialed." LPA contacted administrator Juliet Pacaldo on her cell phone, and conducted this Tele-visit via Facetime. She advised that the phone system is being repaired and should be operable by 6/30/20; it has been out of order since 6/23/20. LPA instructed her to notify all clients and their responsible parties and the Ombudsman, as well as submit written notification to CCLD.

LPA asked Ms. Pacaldo about elopement of client #1 on 6/23/20, and whether or not he was capable of leaving the facility unassisted. She said that he is not, and she submitted his MD report to LPA Hopkins on 6/25/20, as requested. LPA reviewed client's file with assistance from Ms. Pacaldo. LPA requested that she submit the following updated documents:
- client's latest Appraisal
- client's latest Needs and Services Plan
- client's Admission Agreement

Ms. Pacaldo advised that client is currently at SF General Hospital following another elopement yesterday; Incident Report is being prepared and will be submitted to CCLD. LPA advised that despite her reluctance to accept client back to facility if/when he is medically stable, she is obligated to do so. LPA advised her to update client's Appraisal and Needs and Services Plan to include recent elopements, and she may also issue a 30-day notice of eviction if she is unable to provide adequate care and supervision. Until then, and while he remains a resident, client must be monitored closely to prevent him from leaving the facility unsupervised. LPA reminded Ms. Pacaldo that given the current pandemic and shelter in place order, client must also be quarantined for 14 days--even if he tests negative--and not be allowed to roam the facility.
No deficiencies cited today.
************This report is emailed to Ms. Pacaldo for signature. Signed report to be emailed or faxed to LPA at 650/266-8841****************
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:

DATE: 06/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/26/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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