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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 10/30/2024
Date Signed: 10/30/2024 01:04:23 PM

Document Has Been Signed on 10/30/2024 01:04 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/
DIRECTOR:		PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 53TOTAL ENROLLED CHILDREN: 0CENSUS: 51DATE:
10/30/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator, Paula MadrigalTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
NARRATIVE
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On October 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 10/19/24. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

The licensee reported, on 10/19/24 at approximately 10:00am, Resident 1 (R1) signed out of the facility to attend an AA meeting. R1 did not tell staff he/she was leaving and no staff was present at the nurses' station when R1 was signing out to leave the facility. Morning staff med-tech noticed that R1 had not returned back to the facility and notified evening staff, however evening staff did not check in to see if R1 returned back to the facility. Facility called 911 on 10/20/24 at 5:00am and the police department notified staff that R1 was detained.

During the visit, 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, R1 did sign out at 10am on 10/19/24 and it was noted that he/she was going to an AA meeting. 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.

R1 previously left the facility unassisted on 9/24/24, and staff failed to call the police right away to ensure R1 was safe as when staff discovered R1 was not at the facility at 9:15pm, it was not till 11:15pm staff called the police. In-service training was provided to staff on 10/21/24 regarding doing rounds to ensure residents are in the facility and to ensure that if residents are unable to leave the facility unassisted, an escort will be provided to ensure safety of resident.

The facility failed to provide care and supervision as necessary to meet the needs of R1 which resulted into R1 leaving the facility unassisted again. In addition, staff did not know where R1 was until the following morning when staff called the police and was told that R1 was in jail. The facility failed to call all required parties immediately when they observed R1 was not at the facility and the evening shift staff failed to check to see if R1 returned back.

Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. An immediate civil penalty was assessed for Absence of supervision. Failure to correct the deficiency may result in additional civil penalty.

Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalty is also provided.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 10/30/2024 01:04 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: 10/30/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2024
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).

This requirement is not met as evidenced by:
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The Licensee/Administrator will develop a plan to ensure residents are being supervised at all times. Administrator/licensee will provide a copy of the plan to CCL by 10/31/24.
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Based on interviews, due to the absence of supervision, R1 left the facility again unassisted on 10/19/24 and facility staff failed to check to see if R1 returned back to the facility knowing R1 left in the morning which poses an immediate health risks for residents in care. R1 did not return back to the facility till 10/29/24.
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Immediate Civil Penalty of $500.00 is being assessed today 10/30/24 for absence of supervision.

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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: 10/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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