415601066-4-25-2023-14-AS-CSMH-CS7V6H-20230526160933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 04/25/2023
Date Signed: 04/25/2023 04:13:20 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
06/17/2020 and conducted by Evaluator Audrey Jeung

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200617104022

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: 50	DATE:	04/25/2023
		UNANNOUNCED	TIME BEGAN:	03:15 PM
MET WITH:	Buena Balasta and Paula and Oscar Madrigal		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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- Staff are unable to adequately communicate with residents
- Staff do not meet resident's needs
- Staff do not treat residents with dignity and respect
- Food service is poor
- Facility is in disrepair

INVESTIGATION FINDINGS:

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Based on observations and interviews with clients and staff, these allegations are determined to be unsubstantiated.

Even though English is not the first language spoken by most staff, it is not evident that they are not able to communicate with clients. Staff confirmed that they are following facility management's directive that staff speak English whenever clients are present.

Emergency signal system was inspected and tested as operable during past visits. First floor rooms have battery operated pendants that transmit an audible alert to the nurses station. Whoever is at the nurses station will look for and notify the assigned caregiver; there is no walkie talkie or pager. Second floor rooms have a hard wired system that sends an audible alert to a central location as well as turning on a light above the room door, visible in the hallway. Because there is no report, log or record of who called for assistance, nor when, it cannot be determined if clients' needs were not met by staff who failed to respond to clients' emergency calls. Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200617104022

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: 04/25/2023

NARRATIVE

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LPA Jeung observed documentation of personal rights training given to staff in April 2020. Based on interviews conducted by LPA Jeung, no one witnessed clients being treated disrespectfully by staff.

Adequate supplies of perishable and non-perishable foods were observed during LPA's initial virtual visit, and 4-week menu cycle was reviewed. Facility appears to be serving a variety of foods of sufficient quantity. Plates and bowls were inspected on 4/12/22 and were not chipped. See Advisory Note for additional information.

According to administrator, on 5/29/20, there was a leak in the old pipes in the shared bathroom of 1st floor rooms 35 and 36, which affected just this one bathroom; the bathroom wall was wet. Repairs were done by a plumber on 5/30/20, but a repair invoice was not available to confirm this. Other toilets may have been affected and deemed out of order.

Although the allegations may have occurred or are valid, there is not enough evidence to prove the alleged violations did or did not occur.

SUPERVISOR'S NAME: Cara Smith	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Audrey Jeung	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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