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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 04:16:32 PM

Document Has Been Signed on 07/08/2021 04:16 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
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:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Juliet PacaldoTIME COMPLETED:
04:30 PM
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On 07/08/2021, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management inspection in response to an unusual incident report that the facility had self-reported regarding a resident who is unable to leave the facility unassisted.

Today, LPA interviewed administrator Juliet Pacaldo and staff person Tess regarding the incident. The caregiver who witnessed the elopement was not present on this day. Pertinent documents received via email were reviewed regarding the resident. Although the resident does not have dementia he is not allowed to leave the facility unassisted due to his mental status according to physician paperwork received. LPA toured the facility and observed the location of the room of R1 and the door he exited from. The door is alarmed but it was unclear if it was operational at the time of the elopement. Staff were present on the day of the elopement and he was discovered as not in his room during regular room checks.

Deficiency of the RCFE California Code of Regulations, Title 22, Division 6, Chapter 8 is observed and cited on a following page. Report is reviewed with licensee Juliet. Appeal rights given.
SUPERVISORS NAME: Julio Montes
LICENSING EVALUATOR NAME: Jaime Vado
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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Document Has Been Signed on 07/08/2021 04:16 PM - It Cannot Be Edited


Created By: Jaime Vado On 07/08/2021 at 03:46 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/09/2021
Section Cited
CCR
87461(a)(1)

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Mental Condition - The facility shall determine the amount of supervision necessary by assessing the mental status of the prospective resident to determine if the individual:
(1) tends to wander
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Licensee shall develop a plan of correction (POC) to ensure compliance with Sec.87461(a)(1) shall be recieved on how they will address the needs of supervision of R1 and provide an updated assessment of his needs.

POC to be received in CCL by due date.
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Based on observation, the licensee did not comply with the section cited above. During investigation it was found that the resident is not allowed to leave the facility unassisted due to mental condition.
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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.
SUPERVISOR'S NAME:Julio Montes
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 07/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/08/2021


LIC809 (FAS) - (06/04)
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