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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 11/12/2024
Date Signed: 11/12/2024 11:14:25 AM

Document Has Been Signed on 11/12/2024 11:14 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/
DIRECTOR:		PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 53TOTAL ENROLLED CHILDREN: 0CENSUS: 50DATE:
11/12/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:General Manager, Judith MaCalisang TIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On November 12, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 10/30/24. LPA met with General Manager, Judith MaCalisang and explained the purpose of the visit.

On 10/30/24, the facility was issued a citation for California Code of Regulations (CCR) 87465(h)(2) Incidental Medical and Dental Care as LPA observed medications to be unlocked and accessible to residents in care.

During the visit conducted today, LPA observed the medication carts located on the first floor at the nurses' station. LPA observed medications to be all locked and inaccessible to residents. LPA observed a gate that is locked when staff members are not present at the nurses' station. LPA observed the nurses' station on the second floor to have a new door lock. Medication cart on the second floor was observed repaired and locked.

Deficiency is now verified as corrected and cleared.

Report is reviewed with General Manager, Judith MaCalisang and a copy is provided.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 11/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2024
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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