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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 12/03/2020
Date Signed: 12/03/2020 04:55:00 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: 49DATE:
12/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Juliet Pacaldo, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) conducted an unannounced telephonic Case Management with Juliet Pacaldo, Administrator. LPA discussed Activity Director being observed without a mask during bingo playing and residents with no masks and no social distancing. Juliet will comply with mask wearing as she realizes COVID is a concern. Juliet will also comply with social distancing for residents while playing bingo. Although, Memory care Dementia is a challenge at times to have residents to wear masks, Juliet will adhere to social distancing. Facility will adhere to mask wearing for all staff and social distancing for all staff and residents. Visitor temperature checks and visitor log with covid questions will be adhered to for all Visitors coming into facility as well as visitors in Patio area.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha RaygozaTELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2020
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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