415601066-7-1-2022-14-AS-CSMH-CMB2RB-20221220163716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 07/01/2022
Date Signed: 07/01/2022 03:42:50 PM

Unfounded

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
05/10/2022 and conducted by Evaluator Jaime Vado

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20220510164635

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:	DATE:	07/01/2022
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Juliet Pacaldo		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Facility illegally evicted resident

INVESTIGATION FINDINGS:

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On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with licensee Juliet Pacaldo and explained purpose of today's visit.

During the course of the investigation LPA conducted interviews with staff and other outside agencies. It was discovered that R1 was initially sent to the hospital for not taking medications and being aggressive with resdients and staff. He was on a psych hold for 24hrs and was accepted back at the facility the next day. When he returned back to the facility he became destructive and aggressive again breaking a large window at the facility and throwing rocks at cars. The authorities were alerted and R1 was returned back to the hospital for another psych hold where he remains currently. The hospital and Institute of Ageing are looking for placement of R1 as R1 requries a higher level of care. This allegation is unfounded.

This agency has investigated the complaint alleging "facility illegally evicted resident". We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.”

Report is reviewed with the licensee. No citations issued.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (650) 266-8811
LICENSING EVALUATOR NAME: Jaime Vado	TELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2022

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

LIC9099 (FAS) - (06/04)

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