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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 10/30/2024
Date Signed: 10/30/2024 12:57:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/25/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241025084857
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: 51DATE:
10/30/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Paula MadrigalTIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff did not ensure centrally stored medication was locked and inaccessible to residents
INVESTIGATION FINDINGS:
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On October 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

Regarding the allegation, staff did not ensure centrally stored medication was locked and inaccessible to residents, according to the reporting party, it was observed that the nurses' station gate was wide open with a clear view and access to residents' medication bottles. In addition, the reporting party indicated that the gate remained unlocked and open for 5-10 minutes until it was brought to a staff members attention.

During the visit, LPA interviewed staff and observed the nurses' station on the first and second floor. Based on observations, LPA observed nurses' station gate on the first floor open and medication unlocked and accessible to residents. Medication bottles, medication in bubble packs, medication for destruction, and other prescribed medications were observed on top of the medication cart on the first floor. LPA observed the second floor nurses' station and observed medication cart to be unlocked with the key on it. In addition, LPA observed medication pills in a cup on top of the medication cart. At the time of the visit, no staff was observed present in the nurses' station on the second floor and the door was open. Furthermore, it was observed that the medication cart on the second floor is in disrepair and does not lock, and the room door stays unlocked at all times.

Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator and a copy is provided with appeal rights.
Substantiated
Estimated Days of Completion:
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 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 14-AS-20241025084857
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87465(h)(2)
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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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The Licensee/Administrator shall provide a plan to ensure all medication carts and medications are locked and inaccessible to residents at all times and will provide a copy of the plan to CCL by 10/31/24
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Based on observations, LPA observed medications cart on the second floor to be in unlocked and in disrepair as it won't lock. Medication pills were observed on top of the medication cart to be accesible to residents. Medication cart on the first floor was observed unlocked with key attached to it; medication bottles, medication for destruction, medication in bubble packs, along with other prescribed medication were observed on top of the medication cart unlocked and accessible to residents which poses an immediate health risk to residents in care.
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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
LIC9099 (FAS) - (06/04)
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