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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 07/08/2021
Date Signed: 07/08/2021 04:16:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
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: 53DATE:
07/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Juliet PacaldoTIME COMPLETED:
04:15 PM
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On 07/08/2021, Licensing Program Analyst (LPA) Jaime Vado toured facility's building and grounds with with administrator/licnesee Juliet Pacaldo and explained purpose of today's inspection. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring, containment strategies, environmental preparation and cleaning. PPE supply is observed as in place. Medications, toxins and sharps are stored appropriately and inaccessible to clients. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars, non-skid flooring material, and hand washing signs. Soap is available. First-aid kits are inspected and complete. A disaster and mass casualty plan is current. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed and are current. Staff files reviewed and are current with first aid cards and training certifications. LIC808 is present at time of this inspection and it is reviewed with the administrator/licensee. Updates to the LIC808 are being made and will be submitted to the Department when those updates are completed.

No deficiencies cited. Report is reviewed with administrator.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2021
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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