415601066-3-13-2023-14-AS-KHOS-CQCMHA-20230328093714

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:29:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220902084723

FACILITY NAME:	A & J ASSISTED LIVING FACILITY		FACILITY NUMBER:	415601066
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	130 VALE STREET		TELEPHONE:	(650) 755-0411
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	53	CENSUS: 53	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Juliet Pacaldo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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- Staff medically restrain a resident
- Residents wandered away from facility
- Facility grounds are in disrepair

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order close the investigation regarding the allegations referenced above. LPA met with licensee Juliet Pacaldo and explained the purpose of today's visit.

During the investigation LPA conudcted interviews and made observations of the facility buidling and grounds. LPA could not prove or disporve the exact residents who allegedly wandered from the facility. Many residents are able to leave the facility on their own. In regards to facility grounds in disprepair, this is in regards to trash cans the faciltiy provided to residents located outside of the facility so they don't litter. It was found that the trash cans were also being utilized by the public without facility approval so this caused them to overflow. The facility in turn removed the trash cans to prevent the overflow from happening.

Continued on next page...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/02/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220902084723

FACILITY NAME:	A & J ASSISTED LIVING FACILITY		FACILITY NUMBER:	415601066
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	130 VALE STREET		TELEPHONE:	(650) 755-0411
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	53	CENSUS: 53	DATE:	03/13/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Juliet Pacaldo		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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- Facility is in disrepair

INVESTIGATION FINDINGS:

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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit in order close the investigation regarding the allegations referenced above. LPA met with licensee Juliet Pacaldo and explained the purpose of today's visit.

During the investigation LPA conudcted interviews and made observations of the facility buidling and grounds. LPA did observe a broken window facing Vale Street. This allegation is substantiated.

Based on LPA interviews and items letters received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, are being cited on the attached LIC9099D. Report is reveiwed licensee.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 14-AS-20220902084723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/13/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/13/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	Maintenance and Operation - The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.	1 2 3 4 5 6 7	Facility shall ensure that the facility is in good repair at all times in regards to windows and screens. A written correction is to be received by CCLD by the due date.
	8 9 10 11 12 13 14	This regulation has not been met as evidenced by: Per LPA observations made, LPA confirmed a broken window facing Vale Street which is in violation of being in good repair.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 14-AS-20220902084723

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 03/13/2023

NARRATIVE

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Page 2 - LIC9099C

In regards to staff medically restraining a resident, LPA could not find evidence of this happening. A review of medications and medications practices were conducted. Hospice residents were identified and medication orders and administration is reviewed. LPA could not prove or disprove this allegation took place based on interviews and documentation reviewed.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

No citations issued. Report is reviewed with the licensee.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC9099 (FAS) - (06/04)

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