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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:46:12 PM


Document Has Been Signed on 04/25/2023 04:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 50DATE:
04/25/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Paula and Oscar MadrigalTIME COMPLETED:
05:00 PM
NARRATIVE
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During complaint investigation visit, a deficiency of the California Code of Regulations, Title 22 is observed, based on review of file for staff #1, who has been employed since January 2023. Citation appears on a following page.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 04/25/2023 04:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: A & J ASSISTED LIVING FACILITY
FACILITY NUMBER: 415601066

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/26/2023
Section Cited

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CRIMINAL RECORD CLEARANCE
All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility, obtain a CA clearance or a criminal record exemption as required by the Department. This requirement was not met,
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Staff #1 cannot be on premises with contact with clients unless and until he has been fingerprinted and obtain criminal record clearance and association with facility.
Proof of correction to be sent to CCLD BY DUE DATE
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as staff #1 has been employed as caregiver since 1/2023, but there is no evidence of criminal record clearance. Licensee failed to ensure that staff with direct contact with clients maintain criminal record clearance prior to contact with clients, which poses an immediate health, safety or personal rights risk to clients in care. LIC421 issued to assess immediate $500 civil penalty=5 days at $100/day .
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cara SmithTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey JeungTELEPHONE: (650) 266-8891
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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