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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 01/17/2025
Date Signed: 01/17/2025 10:34:41 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
10/11/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241011094829
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: 51DATE:
01/17/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Paula Madrigal TIME COMPLETED:
10:44 AM
ALLEGATION(S):
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Staff did not ensure that facility was free from pests.
Facility is unkempt.
Facility is malodorous.
Staff do not provide adequate laundry service.
INVESTIGATION FINDINGS:
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On January 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

Regarding the allegation, staff did not ensure that facility was free from pests, according to the reporting party, on 10/02/2024 it was observed mice was in the facility and reporting party reported it to the administrator.

During the investigation, LPA toured the facility and reviewed the pest control invoices. During the visit, LPA observed cockroaches on Resident 1’s (R1’s) food and in R1’s bag of personal belongings. LPA observed 2 mice run from one side of the room to the other as R1 was picking up his/her blanket. Based on the pest-control invoices and services provided, the facility hired a third party pest control vendor in September who comes to the facility twice a month to inspect and service the facility. However, despite pest control coming to the facility twice a month, the facility still has pests. According to the Licensee, on 11/12/24, while the caregivers were bringing lunch to a resident, a cockroach was observed on the lid. (Continue to 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
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 5
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
10/11/2024 and conducted by Evaluator Komal Charitra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20241011094829

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:
01/17/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator, Paula Madrigal TIME COMPLETED:
10:44 AM
ALLEGATION(S):
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9
Resident is not accorded dignity and respect.
INVESTIGATION FINDINGS:
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On January 17, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver findings for the above allegations. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

Regarding the allegation, resident is not accorded dignity and respect, according to the reporting party, Resident 1 (R1) is a bariatric resident that lays naked across the bed and the caregivers go to R1's room and do whatever they need to do and leave. In addition, reporting party indicated that R1 does not feel respected as staff do not speak to R1 in a respectful matter.

During the investigation, LPA was unable to interview R1 as R1 is no longer a resident at the facility. The administrator denied this allegation. According to the Administrator, R1 did not want any staff to go into his/her room unless it was to provide food, medication or unless R1 called. Reporting party did not mention any staff members names.

Based on information collected, the department has determined that although the above allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report is reviewed with Administrator, Paula Madrigal and a copy is provided.



Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 14-AS-20241011094829
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: 01/17/2025
NARRATIVE
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Regarding the allegation, facility is unkempt and facility is malodorous, according to the reporting party, during a visit that was conducted on 10/2/24, it was observed R1's room had two mouse traps installed but the room was still unkempt with odor. Reporting party does not believe that the facility is cleaned daily.

During the complaint visit conducted on 10/14/24, LPA observed R1’s room and observed a gallon sized bag of dirty towels, four mouse traps in corners of R1’s room, dishes and food stacked right next to R1’s bed, four baskets of towels, and personal belongings all over R1’s bed; kettle, gloves, tissue paper, WD-40, etc. R1’s room had a urine odor. According to the Administrator, R1 urinates in towels as R1 is bed bound and puts urinated towels in a plastic bag. LPA toured the facility and observed it to have a strong urine odor.

Regarding the allegation, staff do not provide adequate laundry services, according to the reporting party, R1 has four laundry baskets filled with soiled clothing. Reporting party also observed one 32-gallon bag filled with dirty clothing and towels which spilled out onto the floor.

During the complaint visit conducted on 10/14/24, LPA observed a 32-gallon bag filled with dirty clothing and towels. LPA observed cockroaches in the bag. According to the administrator, laundry for R1 was being done twice a week, however the facility does laundry services everyday now. According to R1, the facility is doing laundry everyday, but R1 does not receive his/her clean laundry until a week after.

Based on observations, record review and interviews conducted, the preponderance of evidence standard has been met. Therefore, the above allegations 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 Administrator, Paula Madrigal and a copy is provided with appeal rights.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 14-AS-20241011094829
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: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/18/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1 Personal Rights of Residents in All Facilities: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:

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Licensee/Administrator shall submit a plan in writing to ensure facility is free from pests. Plan should include hird party contractor's name, plan to increase pest control services, and how often third party contractors will come to the facility.
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During the complaint visit, LPA observed cockroaches on Resident 1’s (R1’s) food and in R1’s bag of personal belongings. LPA observed 2 mice run from one side of the room to the other. Based on the pest-control invoices, pest control came into the facility twice a month, however, despite pest control coming to the facility twice a month, the facility still has pests.
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Type B
01/24/2025
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times...

This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan on how to ensure is clean and free from odor. Plan shall include training housekeepers, increasing the amount of times facility gets cleaned, possibly hiring a third party vendor to clean the facility.
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Based on observations, LPA observed R1’s room and observed a gallon sized bag of dirty towels, four mouse traps in corners of R1’s room, dishes and food stacked right next to R1’s bed, four baskets of towels, and personal belongings all over R1’s bed. R1’s room had a urine odor. LPA toured the facility and observed it to have a strong urine od
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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: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 14-AS-20241011094829
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: 01/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/24/2025
Section Cited
CCR
87307(a)(3)(C)
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87307 Personal Accommodations and Services: (a) Living accommodations and grounds shall be related to the facility's function. The facility shall be large enough to provide comfortable living accommodations and privacy for the residents… who may reside in the facility. The following provisions shall apply: (3) Equipment and supplies necessary for personal care and maintenance of adequate hygiene practice shall be readily available to each resident…(C) Clean linen… hand towels and wash cloths. The quantity shall be sufficient to permit changing at least once per week or more often when indicated to ensure that clean linen is in use by residents at all times…

This requirement is not met as evidenced by:
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Licensee/Administrator shall submit a plan in writing to ensure clean linen is readily available to residents. Plan shall include training housekeepers, doing laundry everyday, etc.
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Based on observations, LPA observed a 32-gallon bag filled with dirty clothing and towels. According to R1, the facility is doing laundry everyday, but R1 does not receive his/her clean laundry until a week after.
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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: 01/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5