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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 09/03/2025
Date Signed: 09/03/2025 12:02:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
08/27/2025 and conducted by Evaluator Komal Curley
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250827123554
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: 53DATE:
09/03/2025
UNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Administrator, Paula Madrigal TIME COMPLETED:
12:15 PM
ALLEGATION(S):
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Facility has pests
INVESTIGATION FINDINGS:
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On September 3, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

Regarding the allegation, facility has pests, according to the reporting party, the facility has mice and there are mice droppings in residents bedrooms and in the resident's drawers.

During the visit, LPA interviewed staff, observed residents rooms and reviewed documents. LPA observed mouse traps in four resident rooms. According to staff, there were mice droppings in three resident rooms, however has been cleaned by housekeeping. According to the administrator, the pests started coming when the facility did not have garbage picked up from the facility for 3 weeks. Based on the pest-control invoices provided, the facility hired a third party pest control vendor, Orkin who has been coming to the facility once a week to inspect and service the facility. However, despite pest control coming to the facility once a week, the facility still has pests and the facility did not ensure the facility was free from pests. (continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
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 3
Control Number 14-AS-20250827123554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: A & J ASSISTED LIVING FACILITY
FACILITY NUMBER: 415601066
VISIT DATE: 09/03/2025
NARRATIVE
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Based on observations, record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegations are determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

A civil penalty of $250.00 is being assessed during the visit today for a repeat citation that was issued on 1/17/25 for California Code of Regulation, 87468.1(a)(2) Personal Rights of Residents in All Facilities.

Report was discussed with Administrator, Paula Madrigal and a copy is provided with appeal rights. A copy of the civil penalty is also being provided to the administrator,
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 14-AS-20250827123554
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 09/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/04/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
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Licensee/administrator shall submit a plan in writing to ensure facility is free from pests. Plan should include increasing pest control services, in addition to other ways to ensure facility is free from pests.
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Based on staff interviews, the pests started coming into the facility because there was no trash service for three weeks. Although, pest control is coming into the facility, the facility still has pests and the facility did not ensure the facility was free from pests which poses an immediate health and safety risk to residents in care.
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A civil penalty of $250.00 is being assessed during the visit today for a repeat citation that was issued on 1/17/25
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Curley
LICENSING EVALUATOR SIGNATURE:

DATE: 09/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3