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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 03/27/2025
Date Signed: 03/27/2025 02:45:26 PM

Document Has Been Signed on 03/27/2025 02:45 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:A & J ASSISTED LIVING FACILITYFACILITY NUMBER:
415601066
ADMINISTRATOR/
DIRECTOR:		PACALDO, JULIETFACILITY TYPE:
740
ADDRESS:130 VALE STREETTELEPHONE:
(650) 755-0411
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 53CENSUS: 44DATE:
03/27/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:07 PM
MET WITH:Administrator, Juliet PacaldoTIME VISIT/
INSPECTION COMPLETED:
02:55 PM
NARRATIVE
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On March 27, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrators, Juliet Pacaldo and Paula Madrigal and explained the purpose of the visit.

LPA toured the facility including a random sample of resident rooms, common areas, and kitchen area. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a two story facility. LPA observed resident rooms; some of which are single private rooms and some of which are shared. All resident rooms were observed to be odor-free with all required furniture.
Bathrooms were observed to be clean and odor-free. During the visit, LPA observed a broken hot water faucet in resident's bedroom. Water temperature throughout the facility measured between 130-135 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete.

Dining room was observed free from tripping hazards. A comfortable temperature is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. On the second floor, LPA observed flies right outside the kitchen, with no window or door blocking the flies from going inside the kitchen. LPA observed flies in the kitchen while staff were cooking. Sharps were observed in the kitchen, inaccessible to residents. LPA observed a door near the kitchen in disrepair.

Chemicals were observed locked and inaccessible to residents, however there was a chemical storage room on the second floor near the kitchen had no door knob and a hole in the wall. There was a tie that went through the hole in the wall and the door knob to lock the door. During the tour, LPA observed the medication cart on the first floor to be locked and inaccessible, however LPA observed the nurses' station on the second floor with the key attached on the door. LPA observed multiple staff rooms on the second floor. (continue to 809C).
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/27/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/27/2025
NARRATIVE
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Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of February 2025. Emergency drills are logged and done every three month. LPA reviewed 5 resident records and 5 staff records. LPA observed 2/5 resident admission agreements to not be signed by resident or resident's responsible party. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. Failure to correct the deficiencies may result in civil penalties.

Report is reviewed with Administrators and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/27/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2025
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 03/27/2025 02:45 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/27/2025 at 02:06 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on resident record reviewed, LPA observed 2/5 resident records to not have signed admission agreements which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee/administrator to submit a plan in writing on how to ensure all resident admission agreements are signed and complete.
Type A
Section Cited
CCR
87555(b)(27
87555 General Food Service Requirements: (b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed flies outside of the kitchen with no window or door blocking the flies from going inside the kitchen. In addition LPA observed flies in the kitchen while staff were cooking which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2025
Plan of Correction
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Licensee/administrator shall submit a plan in writing on how to ensure flies are not going into the kitchen while food is being prepared or being served to residents.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/27/2025 02:45 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/27/2025 at 02:15 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation: (e)Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, water temperature throughout the facility measured between 130-135 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Licensee/administrator shall submit photos to LPA of water temperature being within 105-120 degrees F.
Type B
Section Cited
CCR
87303(a)
87303 Maintenance and Operation: (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed the door near the kitchen to be in disrepair. LPA observed the hot water faucet in one resident's room to not be working. In addition, LPA observed a cleaning supply room near the kitchen to have no door knob, and there was a hole observed in the wall. The facility put a tie through the hole in the wall into the hole in door knob hole to lock the door which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/03/2025
Plan of Correction
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Licensee/administrator shall repair all of the above mentioned issues that were observed and send LPA a photo of the repair.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 03/27/2025 02:45 PM - It Cannot Be Edited


Created By: Komal Charitra On 03/27/2025 at 02:24 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: 03/27/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87456(h)(2)
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:
Deficient Practice Statement
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Based on observations, LPA observed the second floor nurses' station that has medication in the room to have the key attached to the door knob with no staff present which poses an immediate health, safety or personal rights risk to persons in care. A CIVIL PENALTY OF $250.00 IS ASSESSED ON 3/27/25 FOR REPEAT VIOLATION WITHIN LAST 12 MONTHS. Deficiency was assessed on 10/30/24
POC Due Date: 03/28/2025
Plan of Correction
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Licensee/Administrator to conduct an in-service training with staff regarding the importance of locking medication and ensuring the key is not attached to the door.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Charitra
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/27/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2025


LIC809 (FAS) - (06/04)
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