415601066-12-12-2023-14-AS-KHOS-D32RYQ-20240304122642

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 12/12/2023
Date Signed: 12/12/2023 11:31:36 AM

Unfounded

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
03/08/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230308102358

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: 52	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	09:30 PM
MET WITH:	April Pacaldo.		TIME COMPLETED:	11:35 PM

ALLEGATION(S):

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- Facility is in financial distress.

INVESTIGATION FINDINGS:

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13

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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 2

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
03/08/2023 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20230308102358

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: 52	DATE:	12/12/2023
		UNANNOUNCED	TIME BEGAN:	09:30 PM
MET WITH:	April Pacaldo.		TIME COMPLETED:	11:35 PM

ALLEGATION(S):

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- Facility has pests
- Facility is not maintained clean an sanitary
- Facility does not ensure that residents are adequately fed
- Facility does not ensure that residents have privacy in their rooms
- Facility is in disrepair
- Facility does not ensure that residents are supplied toilet paper
- Facility is unable to meet the needs of some residents
- Facility does not provide a safe environment for residents and staff
- Facility does not have adequate equipment to meet the needs of some residents
- Facility is not maintained at a comfortable temperature for the residents

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to investigate further the allegations received and deliver findings. LPA met with assistant administrator April Pacaldo and explained the purpose of today's visit.

During the course of the investigation LPA conducted interviews, reviewed documents, and made observations through out the facility. Interviews conducted with residents and staff could not prove or disprove the above allegations took place. Observations made do not reflect the disrepair and sanitary conditions alleged. Pest control is in place and LPA did not observe pests or droppings to indicate that there is an issue with pests. Meal plans and observations made show food is in place. Interviews conducted showed that if residents wants an extra portion or more food it is provided depending on dietary plan. Ambient temperature is comfortable during visits made to the facility and when observations were made including the second floor of the facility. Room privacy is accorded upon request such as partitions or curtains to provide privacy. LPA observed some resident rooms as having such in place or having furniture arranged to accord privacy. Toiletries are provided upon request from the nurses station per interviews conducted. Interviews conducted show that difficult residents have plans in place and the facility will work with their responsible parties to meet their needs including the use of specialized equipment if necessary. The above allegations are unsubstantiated.

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.

Report is reviewed with April.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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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