415601066-8-26-2025-14-AS-ACON-DLDRQ6-20250910131300

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601066
Report Date: 08/26/2025
Date Signed: 08/26/2025 11:32:43 AM

Unsubstantiated

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
08/21/2025 and conducted by Evaluator Komal Charitra

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20250821094037

FACILITY NAME:	A & J ASSISTED LIVING FACILITY		FACILITY NUMBER:	415601066
ADMINISTRATOR:	PACALDO, JULIET		FACILITY TYPE:	740
ADDRESS:	130 VALE STREET		TELEPHONE:	(650) 755-0411
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94014
CAPACITY:	53	CENSUS: 51	DATE:	08/26/2025
		UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Administrator, Paula Madrigal		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Staff did not seek medical attention for resident.
Staff mismanages resident's medications.

INVESTIGATION FINDINGS:

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On August 26, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced 10-day complaint visit. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit.

Regarding the allegation, staff did not seek medical attention for resident, according to the reporting party, Resident 1 (R1) was complaining of pain (unsure duration of pain) and Staff 1 (S1) was aware of R1’s pain, however did not seek medical attention for R1.

During the visit, LPA interviewed staff and R1. According to 3/3 staff interviewed, they were not aware of R1 complaining of any pain. According to S1, when notified of R1's pain by third party individual, S1 checked on R1 and asked if R1 needed to go to the hospital or if R1 needed pain medication, however R1 refused. S1 continued to check on R1 until he/she was sent to the hospital. According to R1, he/she was in pain for approximately 6 days, however did not notify any staff of his/her pain. (Continue to 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250821094037

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: 08/26/2025

NARRATIVE

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Regarding the allegation, staff mismanages resident's medications, according to the reporting party, it was observed that staff have been incorrectly documenting R1’s Olanzapine dosage. According to the medication log, the facility has documented that R1’s Olanzapine dosage is 40mg daily at bedtime, however the correct dosage is only 2.5mg at bedtime.

During the investigation, LPA reviewed R1’s file including but not limited to; physician's orders for medication, medication administration record (MAR), and R1's medication bottles. According to staff interviewed, R1 is receiving the correct dosage of Olanzapine as prescribed by the physician, however the new electronic MAR system listed the Olanzapine medication dosage incorrectly. LPA reviewed R1’s medication bottle and observed it to show that R1 is supposed to receive 2.5mg of Olanzapine daily at bedtime. Medication count was conducted and all medications are accounted for. Facility MAR was reviewed, and the facility corrected the dosage error on their electronic system. Although the MAR system listed the dosage for R1’s Olanzapine incorrectly, the facility is administering R1’s medication as prescribed by the physician.

Based on interviews conducted, records reviewed, observations, and information collected, the department has determined that although the above allegations may have happened or are valid, there is no preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are UNSUBSTANTIATED.

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

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Komal Charitra
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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