415601066-4-8-2021-14-AS-JMOS-C2AP2G-20210421105555

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 04/08/2021
Date Signed: 04/08/2021 02:21:21 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/01/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210201150634

FACILITY NAME:	A & J ASSISTED LIVING FACILITY		FACILITY NUMBER:	415601066
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	130 VALE STREET		TELEPHONE:	(650) 755-0411
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	53	CENSUS: 49	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Juliet Pacaldo,		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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- Facility failed to ensure residents have safe accommodations to meet resident's needs

INVESTIGATION FINDINGS:

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On 4/8/2021, Licensed Program Analyst (LPA) Han conducted an unannounced follow-up complaint inspection with the Administrator, Juliet Pacaldo over the phone and delivered the findings. Due to COVID-19 and health and safety concerns, LPA Han was not present in the facility. LPA Han spoke to the Administrator and explained the purpose of the phone call.

Regarding facility failed to ensure residents have safe accommodations to meet resident's needs. The investigation was started by LPA Raygoza and reassigned to LPA Han. The complainant stated that the residents lacked beds with the ability to move to raise the resident's head up during eating. No further information was provided. The Assisted Living facilities are not required to provide hospital beds nor hospital equipment but are required to need the needs of each resident and to meet physician's recommendation for postural support equipment.

LPA Han interviewed the Administrator who stated that caregivers check equipment during their shift and when they identify an equipment that is not working such as a bed, they report it to the maintenance staff right away and if the maintenance staff can not fix it, they would call the company where the bed came from and seek for further assistance. LPA Han interviewed 3 staff members and they concurred with the Administrator. In addition, they also reported that if a bed is broken and if the facility has an extra one, they would change it for the resident. Furthermore, LPA Han interviewed three residents and all of them reported that the facility is providing safe accommodations to meet their needs. After investigation, this allegation is unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is unsubstantiated.

Cont on LIC 9099A

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

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

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/01/2021 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20210201150634

FACILITY NAME:	A & J ASSISTED LIVING FACILITY		FACILITY NUMBER:	415601066
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	130 VALE STREET		TELEPHONE:	(650) 755-0411
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	53	CENSUS: 49	DATE:	04/08/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Juliet Pacaldo,		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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5
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7
8
9

- Facility failed to maintain physical plant of the facility
- Facility failed to ensure safe working conditions for staff

INVESTIGATION FINDINGS:

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3
4
5
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7
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9
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12
13

On 4/8/2021, Licensed Program Anayst (LPA) Han conducted a follow-up complaint via phone with the Administrator, Juliet Pacaldo and delivered the findings. Due to COVID-19 and health and safety concerns, LPA Han was not present at the facility.

This investigation was started by LPA Raygoza and reassigned to LPA Han. The allegation that the facility failed to ensure safe working conditions for staff is beyond the scope and jurisdiction of this agency and falls under the purview of either the labor department or OSHA. Therefore, the allegation is determined unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Regarding to facility failed to maintain physical plant, LPA Han conducted a virtual tour and observed the facility to be cleaned, tidy and equipment is in good working condition. LPA Han interviewed three residents and they reported that the facility is maintaining their physical plant. LPA Han interviewed 5 staff members and they reported that the facility is in good shape and is cleaned. Based on interviews and observation, the investigation is determined unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Murial Han	TELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 2 of 2