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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 10/14/2024
Date Signed: 10/14/2024 01:54:22 PM


Document Has Been Signed on 10/14/2024 01:54 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: 53DATE:
10/14/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Paula MadrigalTIME COMPLETED:
02:15 PM
NARRATIVE
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On October 14, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to an incident that occurred on September 23, 2024. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

On September 24, 2024, the Licensee reported that on September 23, 2024, Resident 1 (R1) signed out from the facility at 10:15am to go to his/her doctor's appointment. After the doctor's appointment, R1 called 911 due to the foot of his/her wheelchair getting stuck. Facility called 911 and filed missing persons at 11:15pm because R1 was observed not to be at the facility at 9:15pm when med-tech noticed.

During the investigation, LPA reviewed documents and interviewed administrator. LPA observed the resident sign-in and sign-out log located in front of the nurse's station. According to the log observed, on 9/23/24, R1 signed out to go to a doctor's appointment at 9:45 am. Based on file reviewed, R1's physician's report dated 5/3/24 indicated R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. According to the administrator and staff interviewed, R1 has been going in and out of the facility without assistance for months. Based on interviews, it was indicated that on 9/23/24, R1 did not have a staff escort him/her to go out to the doctor's appointment because R1 has been doing it for months without staff accompanying him/her. Facility was unaware where R1 was as he/she did not have a cell phone for staff to reach R1 at. According to the administrator, it was not till 9:15pm when a staff noticed that R1 was not at the facility and not until 11:15pm when staff called the police for a missing person's.

Nevertheless, facility failed to check in on R1 after his/her doctor's appointment and ensure R1 was safe as he/she was not back at the facility. In addition, facility failed to call the police right away when staff noticed that R1 was not back at the facility at 9:15pm.

Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with Administrator. A copy of this report and the Appeal Rights is provided.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
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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Document Has Been Signed on 10/14/2024 01:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/14/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2024
Section Cited
CCR
87464(f)(1)

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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c)

Violation of this regulation is not met as evidenced by:
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Licensee/Administrator will provide in-service training to all staff members regarding checking to ensure residents who are signing-out have a staff member escorting them if required.
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Based on file reviewed, Based on R1's physician's report, R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. According to interviewes, on 9/23/24, R1 did not have a staff escort R1 to his/her doctor's appointment. According to the administrator, it was not till 9:15pm when a staff noticed that R1 was not at the facility and not until 11:15pm when staff called the police for a missing person's. Facility failed to ensure required parties were called immediately after noticing R1 was not at the facility.
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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 CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 629-4305
LICENSING EVALUATOR SIGNATURE:
DATE: 10/14/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/14/2024
LIC809 (FAS) - (06/04)
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