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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
415601066
Report Date:
10/14/2022
Date Signed:
10/14/2022 12:43:11 PM
Document Has Been Signed on
10/14/2022 12:43 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
SF COASTAL AC/SC
,
851 TRAEGER AVE., SUITE 360
SAN BRUNO
,
CA
94066
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:
51
DATE:
10/14/2022
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
12:10 PM
MET WITH:
Tess Yee
TIME COMPLETED:
12:45 PM
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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit to investigate the death of R1 that occurred on 10/13/2022. LPA spoke with the licensee/administrator Juliet Pacaldo via telephone to discuss purpose of visit. LPA met with facility manager Tess Yee.
The Department received all documents requested from the facility on 10/13/2022. LPA discussed specifics with Tess in person and Juliet via telephone. According to them the death occurred off site while R1 was out with a friend. The friend routinely took R1 out for lunch and is a recognizable and familiar visitor. Visitor log is reviewed and it confirmed the frequency of visits that was made to R1. The facility does not have specifics due to this death being investigated by Daly City Police Department (DCPD). Next of kin and responsible parties have been notified and involved. Facility does not have information regarding time and location of death due to the ongoing investigation with DCPD. Facility has requested a death certificate to be provided from Coroner but has not yet received. A case number is provided to LPA as well as the contact information of the dectives investigating the case.
No citations issued.
Report discussed with Tess Yee.
SUPERVISOR'S NAME:
Cara Smith
TELEPHONE:
(650) 266-8800
LICENSING EVALUATOR NAME:
Jaime Vado
TELEPHONE:
(559) 476-9353
LICENSING EVALUATOR SIGNATURE:
DATE:
10/14/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/14/2022
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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