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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 02/19/2021
Date Signed: 02/19/2021 04:41:42 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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: 46DATE:
02/19/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Juliet PacaldoTIME COMPLETED:
03:05 PM
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On this date, Licensing Program Analyst (LPA) Michael Garcia made an unannounced Case Management tele-visit at the facility in response to an unusual incident that the facility had self-reported. The tele-visit was conducted with Juliet Pacaldo, administrator.

LPA interviewed Juliet and Staff 1 (S1), via telephone, and Resident 1 (R1), via video call.

R1 and Resident 2 (R2)'s Physician's Reports were received via email along with corresponding police incident case number.

Administrator shall provide an addendum to the February 12, 2021 Unusual Incident Report and email it to LPA within 24 hours.

This report was reviewed and discussed with Juliet at the end of the visit.

An electronic copy of the report was emailed to Juliet for signature.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Michael GarciaTELEPHONE: (650) 380-4608
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2021
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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