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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 12/22/2023
Date Signed: 12/22/2023 10:26:48 AM


Document Has Been Signed on 12/22/2023 10:26 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 FACILITYFACILITY NUMBER:
415601066
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY:53CENSUS: 50DATE:
12/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:LVN Judith MacalisongTIME COMPLETED:
10:30 AM
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to a possible gas leak reported to the Department on 12/20/2023. LPA met with LVN Judith Macalisong and explained the purpose of today's visit.

On 12/20/2023, the facility was alerted of the smell of gas coming from the facility. Local PG&E and fire department was notified of the smell and inspections were made. It was found out that the source of the gas leak was a broken water heater component from one of the two water heaters the facility is equipped with. The water heater in question is located in a mechanical room at the exterior of the facility adjacent to the activity room on the east side of the facility. During today's visit LPA toured the facility and took water temperatures in two locations. LPA tested the water as 115F and 118F. LPA observed the new water heater components in place as well as the water heater. The facility reported no shortages during the evening hours of 12/20/2023. The facility had warm water, heating, and ability to cook meals. The gas supply to the facility was not shut off. The repairs were made on 12/21/2023 before noon time according to the licensee Juliet Pacaldo.

No citations are issued.

Report is reviewed with Judith.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2023
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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