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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:28:09 PM


Document Has Been Signed on 04/12/2024 02:28 PM - 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: 49DATE:
04/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Juliet PacaldoTIME COMPLETED:
03:00 PM
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On 04/12/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - annual continuation visit in order to review the files of both residents and staff in the facility. LPA met with administrator Juliet Pacaldo and explained the purpose of today's visit.

During today's visit LPA reviewed 5 resident files and 5 staff files in order to ensure they are current and up to date. Per files reviewed all files were complete and contained the required documents. The facility does not handle resident cash resources or physical monies. Facility conducts regular disaster and fire drills accordingly last conducted 01/02/2024.

The following updated forms are being requested to be received by 04/19/2024:

• LIC610D Emergency Disaster Plan
• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• Updated administrator certificate
• LIC9020 Client Roster
• Certificate of Liability Insurance

No citations issued. Report is reviewed with administrator Juliet Pacaldo.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2024
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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