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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 01/31/2023
Date Signed: 01/31/2023 12:27:53 PM

Document Has Been Signed on 01/31/2023 12:27 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 FACILITYFACILITY NUMBER:
415601066
ADMINISTRATOR:PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 53CENSUS: DATE:
01/31/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Tessa Marie YeeTIME COMPLETED:
12:30 PM
NARRATIVE
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On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management visit in regards to the facility accepting and retaining a resident with a Stage 3 pressure sore. LPA met with manager Tessa Marie Yee and explained the purpose of today's visit.

According to a verbal report made by an outside agency on 01/27/2023 the department discovered that the resident was accepted at the facility on 01/22/2023. The facility retained this resident without the approval of an exception request. The facility did send an exception request on 01/20/2023 but did not wait for department approval of the exception request. The resident received home health services while in the facility for the duration. The resident started hospice on 01/27/2023 according to the licensee.

Due to the facility accepting and retaining a resident with a stage 3 pressure sore without an approved exception, there has been a violation of Title 22 regulations. Citations are issued on attached LIC809D pages.

Report is reviewed with manager Tessa.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 01/31/2023 12:27 PM - It Cannot Be Edited


Created By: Jaime Vado On 01/31/2023 at 12:04 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: 01/31/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/01/2023
Section Cited
CCR
87615(a)(1)

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Prohibited Health Conditions - Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:(1) Stage 3 and 4 pressure injuries.
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The facility shall ensure that the a plan will be implemented in order to prevent this situation from happening in the future. A written plan shall be received outlining the understanding of this regualtion and actions the facility will take before accpeting any residents with conditions requiring an exception.
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This regulation has not been met as evidenced by: It was discovered that the facility accepted and retained a resident with Stage 3 pressure sore without prior approval by the Department to allow the resident to be accepted into the facility.
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POC to be received by due date
Type A
02/01/2023
Section Cited
CCR87455(a)

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Acceptance and Retention Limitations - Acceptance or retention of residents by a facility shall be in accordance with the criteria specified in this article 8 and Section 87605, Health and Safety Protection, and the following.
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The facility shall ensure that the a plan will be implemented in order to prevent this situation from happening in the future. A written plan shall be received outlining the understanding of this regualtion and actions the facility will take before accpeting any residents with conditions requiring an exception.
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This regulation has not been met as evidenced by: It was discovered that the facility accepted and retained a resident with Stage 3 pressure sore without prior approval by the Department to allow the resident to be accepted into the facility.
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POC to be received by due date
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:Cara Smith
LICENSING EVALUATOR NAME:Jaime Vado
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023


LIC809 (FAS) - (06/04)
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