415601066-7-23-2024-14-AS-ACON-D7PV2F-20240731160304

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 07/23/2024
Date Signed: 07/23/2024 11:35:22 AM

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
07/16/2024 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20240716115017

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:	07/23/2024
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Medication Technician, Ivy Hautea		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff are not maintaining a complete record for residents.

INVESTIGATION FINDINGS:

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On July 23, 2024, Licensing Program Analyst (LPA), Murial Han conducted a 10-day complaint visit. Upon entrance, LPA met with Medication Technician, Ivy Hautea and explained the purpose of the visit. An additional Medication Technician, Authur Santos and the Manager, Judith MaCalisang arrived momentarily and assisted with the visit.

Regarding to the allegation of- staff are not maintaining a complete record for residents, the reporting party stated that the doctors have observed the Medication Administration Records (MARs) for resident #1 (R1) and resident #2 (R2) were incomplete or missing altogether.

As part of the investigation, LPA reviewed the MARs for R1 and R2 and interviewed facility's staff members.

Based on the documents provided, LPA observed many omissions on R1 and R2's MARs for May and July, 2024 on different shifts and there was no explanations as to why the medication was not administered.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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-20240716115017

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: 07/23/2024

NARRATIVE

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According to the facility's Medication Technicians (Med Techs) and the manager, there should not be omissions on the MARs and the Med Techs should document on the MAR the reason that the medication was not administered.

After the investigation, this allegation is deemed to be substantiated.

Based on observations, interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was 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.

The report is reviewed and discussed with the manager; a copy is provided with the Appeal Rights.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20240716115017

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: 07/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 07/30/2024 Section Cited CCR 87465(a)(6)	1 2 3 4 5 6 7	87465 Incidental Medical and Dental Care..a)A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.	1 2 3 4 5 6 7	The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff education. The administrator/licensee will submit a copy of the plan to CCL by 7/30/2024.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on observation, record review and interview, facility did not ensure R1 and R2's MARs were completed which posed a potential health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC9099 (FAS) - (06/04)

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