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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 08/20/2024
Date Signed: 08/20/2024 10:42:01 AM


Document Has Been Signed on 08/20/2024 10:42 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:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Manager, Judith MaCalisangTIME COMPLETED:
10:50 AM
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On August 20, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with manager, Judith MaCalisang and explained the purpose of today's visit.

On August 9, 2024, the facility reported to the Department that on August 8, 2024, resident #1 (R1) reported that staff #1 (S1) bended his/her fingers and S1 slapped his/her face.

During today's visit, LPA collected documents.

No deficiency is cited today.

This report is reviewed and discussed with the manager.

A copy is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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