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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601066
Report Date: 11/12/2025
Date Signed: 11/12/2025 01:31:16 PM

Document Has Been Signed on 11/12/2025 01:31 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: 50DATE:
11/12/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Assistant Administrator, Gabriel Mendoza TIME VISIT/
INSPECTION COMPLETED:
01:45 PM
NARRATIVE
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On November 12, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case- management visit in relation to an incident that occurred on 9/24/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit.

The Licensee reported on September 24, 2025 at around 7:00pm, the police officers arrived to the facility with Resident 1 (R1). Licensee indicated R1 was found a block away from the facility and staff are unaware how R1 was able to leave unseen. When staff made rounds at 6:30pm, R1 was observed in his/her room.

During the visit today, LPA interviewed assistant administrator, reviewed R1's file, and toured the facility to check the exit door alarms. LPA checked 5 exit doors on the first floor; of which 2 did not have alarms (including front door), 2 were off but working, 1 was working, and 1 that requires replacement. The exit door on the ramp was observed working but turned off. LPA checked 4 exit doors on the second floor, of which 3 were observed working, 1 observed not to have an alarm at all. Based on R1's physician report reviewed dated 12/21/24, R1 has dementia, is confused, disoriented, and unable to leave the facility unassisted. Although R1's physician's report indicated R1 does not have a wandering behavior, based on R1's reappraisal dated, 12/5/25, the facility noted R1 to be a wanderer and is confused and forgetful.

According to the assistant administrator and the staff schedule reviewed from September 24, 2025, there were 3 caregivers on the first floor, 2 caregivers on the second floor and 1 med-tech throughout the entire facility during PM shift on 9/24/25. The assistant administrator indicated the staff did not see R1 elope from the facility. According to the assistant administrator and observations, the front entrance door does not have any locks or alarms and is unlocked 24/7. (continue to 809C).
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2025
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 4
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: 11/12/2025
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The Licensee failed to provide care and supervision as necessary to meet the needs of R1 after noting on R1's reappraisal that R1 is a wanderer, has confusion and forgetfulness which resulted into R1 leaving the facility unassisted without staff being aware.

Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D.

A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1).

Report is reviewed with the assistant administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Curley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 11/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/12/2025 01:31 PM - It Cannot Be Edited


Created By: Komal Curley On 11/12/2025 at 11:15 AM
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: 11/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/13/2025
Section Cited
CCR
87464(f)(1)

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87464 Basic Services: (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).

This requirement is not met as evidenced by:
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Licensee/administrator shall conduct an in-service training with staff regarding elopement risk/wandering behavior. Sign-in sheet shall submitted to LPA. Licensee/administrator shall submit a plan in writing on how to ensure care and supervision is provided to residents who are elopement risk and have wandering behaviors.
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Based on R1’s file reviewed, R1 has dementia, is unable to leave the facility unassisted and is a wanderer, however on 9/24/25, R1 eloped from the facility and was brought back to the facility by police officers at around 7pm. According to the assistant administrator, the staff on the second floor did not see R1 leave the facility and are not sure how R1 left the facility which poses an immediate health and safety risk to residents in care.
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A Civil penalty of $1,000.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). The same citation was issued on 2/11/25.
Type A
11/13/2025
Section Cited
CCR87705(d)

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87705 Care of Persons with Dementia: (d) The licensee shall ensure that the facility has an auditory device or other staff alert feature to monitor exits on exterior doors...accessible to those residents who may be at risk for elopement...

This requirement is not met as evidenced by
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Licensee/administrator will install and/or replace the alarms on exit on the exterior door and will provide LPA video/photos of alarms to be in good working condition. In addition, Licensee/administrator shall conduct an in-service training with staff to ensure that door alarms are turned on at all times.

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Based on observations, LPA observed 11 exit doors thoughout the facility; of which 3 doors did not have alarms, 3 doors with working alarms but were turned off, and 1 that was not working at all. According to R1's file, R1 has dementia, is a wanderer and is unable to leave the facility unassisted, however the Licensee failed to ensure the door alarms were in good working condition which poses an immediate 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Komal Curley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 11/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2025


LIC809 (FAS) - (06/04)
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