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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 12/26/2024
Date Signed: 12/26/2024 10:37:51 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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
12/19/2024 and conducted by Evaluator Komal Charitra
COMPLAINT CONTROL NUMBER: 14-AS-20241219201154
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:
12/26/2024
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Licensee, Juliet Pacaldo and Administrator, Paula Madrigal TIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff mismanaged resident's medication.
Staff did not ensure centrally stored medication was inaccessible to residents
INVESTIGATION FINDINGS:
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On December 26, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Licensee, Juliet Pacaldo and Administrator, Paula Madrigal and explained the purpsose of the visit.

Regarding the allegation, staff mismanaged resident's medication, according to the reporting party, medication list provided by staff had incorrect dosage listed for resident's Trazodone. The reporting party indicated, Resident 1 (R1) is prescribed 75mg of Trazodone once daily at bedtime, and facility med list had it listed incorrectly as 50 mg daily at bedtime.

During the investigation, LPA reviewed R1's file, R1's medication administration record (MAR), and R1's medication list. Based on the MAR and medication list reviewed, it indicates that R1 is being provided a 50mg tablet of Trazodone by mouth at bedtime, however based on R1's medication's observed and doctor's order, R1 is actually receiving 75mg of Trazodone which was obesrved in bubble packs and was observed on the doctor's orders. Nevertheless, the facility failed to ensure that the medication list and MAR were correct and matched the dosage that was being provided to R1 based on doctor's orders.

Regarding the allegation, staff did not ensure centrally stored medication was inaccessible to residents, according to the reporting party, clinical documentation and medications for various patients were again noted to be placed in non-secure portions of the nursing station.

(Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 14-AS-20241219201154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: A & J ASSISTED LIVING FACILITY
FACILITY NUMBER: 415601066
VISIT DATE: 12/26/2024
NARRATIVE
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During the visit conducted on 12/23/24, LPA toured the facility’s nursing station on the first and second floor. LPA observed a full box of medications for various residents on the floor in the nurses’ station to be unlocked and accessible to residents in care. LPA observed the second-floor nurses’ station and observed a prescribed bottle of Gavilyte in an unlocked cabinet. According to the General Manager, the pharmacy delivered medication either early in the morning or during NOC shift. The General Manager indicated he/she came in around 6am, however was busy and was unable to lock the medication.

Based on observations, record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegation are determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Licensee, Juliet Pacaldo and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 14-AS-20241219201154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/27/2024
Section Cited
CCR
87465(h)(2)
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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
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The Licensee/Administrator shall provide a plan to ensure all medications and confidential documents are locked and inaccessible to residents in care.
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During the visit conducted on 12/23/24, LPA toured the facility’s nursing station on the first and second floor. LPA observed a full box of medications for various residents on the floor in the nurses’ station to be unlocked and accessible to residents in care. LPA observed the second-floor nurses’ station and observed a prescribed bottle of Gavilyte in an unlocked cabinet which poses an immediate health and safety risk to residents in care
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A civil penalty of $250 will be assessed for a repeat violation within 12 months. This deficiency was cited on 10/30/24 and will be cited again on 12/26/24
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 14-AS-20241219201154
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 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: 12/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/02/2025
Section Cited
CCR
87465(h)(6)(C)
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87465 Incidental Medical and Dental Care:
(h) The following requirements shall apply to medications which are centrally stored:
(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained...

This requirement is not met as evidenced by:


(C) The drug name, strength and quantity.
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Licensee/Administrator shall submit a plan in writing on how to ensure the facility/med-techs will ensure that the MAR and medication list for each resident matches the doctor's orders.
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Based on the MAR and medication list reviewed, it indicates that R1 is being provided a 50mg tablet of Trazodone by mouth at bedtime, however based on R1's medication's observed and doctor's order, R1 is actually receiving 75mg of Trazodone which was obesrved in bubble packs and was observed on the doctor's orders which poses a potential health and safety risk to residents in care
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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.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 12/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4