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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 02/26/2024
Date Signed: 02/26/2024 02:53:11 PM


Document Has Been Signed on 02/26/2024 02:53 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: 52DATE:
02/26/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Administrator - Juliet PacaldoTIME COMPLETED:
12:30 PM
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On 02/26/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Juliet Pacaldo and explained the purpose of today's visit.

This is a two level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen not accessible to resident. Cleaning solutions are also locked. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and not accessible to residents. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility, smoke detector/carbon monoxide detectors are observed in place, and central heating system. PPE and additional food supplies are observed as in place in the garage. Laundry area is also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Cleaning supplies are observed locked and not accessible to resident. COVID PPE and resident incontinence supplies are observed in place.

This annual inspection be continued at a later date.

Report is reviewed with Juliet. No citations issued.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE: 02/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/26/2024
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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