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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 02/11/2025
Date Signed: 02/11/2025 12:28:22 PM

Document Has Been Signed on 02/11/2025 12:28 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:
02/11/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Administrator, Paula Madrigal TIME VISIT/
INSPECTION COMPLETED:
12:38 PM
NARRATIVE
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On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that occurred on January 29, 2025. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

On 1/29/25, the Licensee reported, Resident 1 (R1) eloped from the facility. At 10:30am, the Daly City Police Officer came to the facility to report that R1 was found on the street and that he/she fell out of his/her wheelchair and smelled like alcohol. The police had a hold on him and took him to the hospital. All required parties were notified.

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 not sign out when he/she left the facility. Administrator indicated that R1 left from the upstairs back door. Based on file reviewed, R1's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted.

According to the Licensee, the med-tech on duty gave R1 his/her medication around 8:30am/9am in R1's bedroom, however after that staff did not observe R1 leave the facility. The facility failed to provide care and supervision as necessary to meet the needs of R1 which resulted into R1 eloping from the facility from the back door and resulting in R1 having a fall while in a wheelchair.

Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1).

Report is reviewed with the administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2025
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 02/11/2025 12:28 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: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
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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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's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted. According to administrator, staff did not observe R1 leave the facility. R1 did not have a staff escort R1 when leaving the facility.
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A repeat civil penaty is assessed today for a repeat violation within 12 months. Same violation was cited on 10/30/24.

$1,000.00 civil penalty is provided on 2/11/25.

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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.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2025

LIC809 (FAS) - (06/04)
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