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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 09/10/2024
Date Signed: 09/10/2024 11:26:59 AM


Document Has Been Signed on 09/10/2024 11:26 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: 53DATE:
09/10/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Administrator, Paula MadrigalTIME COMPLETED:
11:35 AM
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On September 10, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted a follow-up case management in relation to the case management visit that was conducted on 8/20/2024. LPA met with Administrator, Paula Madrigal, and explained the purpose of the 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 the visit, LPA discussed the incident with Paula, reviewed S1's training records, interviewed R1, and interviewed witness (S2).

According to R1, S1 bent R1's fingers and slapped R1 after R1 refused to be changed. R1 indicated there was another staff member present but did not remember who it was. In addition, R1 indicated that he/she did report it to a nurse but did not remember the nurse's name. LPA interviewed S2 who indicated that he/she was with S1 during the time of the incident and did not observe any physical abuse. In addition, according to S1, he/she stated they were aware of the abuse complaint filed against him/her but denied allegations and indicated he/she did not do it.

Based on the incident report, an assessment was done on R1 and there were no bruising, swelling noted. In addition, there were no complaints of pain. LPA reviewed S1 and S2's training record and observed that it was up to date. Facility administrator provided additional abuse training on 8/8/2024 after this incident occurred. According to the administrator, this is the first complaint of abuse that was filed against S1.

No deficiencies were issued during this visit. LPA reviewed the report with Administrator, Paula Madrigal. A copy is provided by email due to technical issues with printer.


SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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