A & J Assisted Living Facility

Type of visit: Required - 1 Year

On March 26, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced annual inspection. LPA met with Administrator, Juliet Pacaldo 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. Some resident rooms were observed to be single private rooms and some were observed to be shared rooms. Resident rooms had required furnishings. Three shower rooms were observed with non-skid mats. Bathrooms were observed to be odor-free. Water temperature throughout the facility was within regulatory requirements. LPA observed window screens in some resident rooms to be broken or ripped. 2nd floor dining room also was observed to have a window screen in disrepair. A comfortable temperature of 70 degrees is maintained in the facility and lighting is sufficient for comfort. LPA observed 2 days for perishables and and 7 days non-perishable. Medications, sharps and chemicals were locked and inaccessible to residents. Emergency drill are being conducted and logged every 3 months. Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current. Five resident records and five staff records were reviewed. Resident records are updated, complete and signed. 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. A copy of civil penalty is provided. Report is reviewed with Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Mar 26, 2026

The state marks this report as 4 pages; the online copy we transcribed has 3. You can request the full file from the county licensing office.

Type of visit: Case Management - Incident

On January 13, 2026, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case-management visit to follow up on an incident that occurred on 1/1/26. LPA met with Assistant Administrator, Paula Madrigal and explained the purpose of the visit. The Licensee reported on 1/1/26 at around 5:30pm, Resident 1 (R1) was no where to be found in the facility. 911 was called. According to the Licensee, the police notified the administrator that R1 is using two names. During the visit, LPA reviewed R1's file, interviewed assistant administrator, and reviewed documents. According to the assistant administrator and day-shift manager, R1 left without staff being aware. When staff on shift were interviewed, they indicated that they did not see R1 leave the facility. R1 has still not returned back to the facility and is still missing. Based on R1's file reviewed, R1 has a diagnosis of a traumatic brain injury with neurological deterioration and is unable to leave the facility unsupervised due to his/her poor judgement. In addition, based on the sign in/sign out log reviewed, R1 did not sign out prior to leaving the facility so staff were not aware where R1 went. Nevertheless, the facility failed to provide care and supervision to R1 resulting in an elopement. 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 $250.00 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.the state’s words, verbatim · CDSS document, Jan 13, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Jan 14, 2026

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: Based on R1’s file reviewed, R1 has is unable to leave the facility unassisted, however, R1 was able to leave the facility on 1/1/26 without staff knowing. In addition, R1 has still not returned back to the facility and is currently missing which poses an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Jan 13, 2026

Plan of correction: Licensee/administrator shall submit a plan in writing on how to ensure residents who are unable to leave the facility unassisted are being monitored and are being provided adequate supervision to ensure safety. A civil penalty of $250.00 is assessed for a repeat violation within the last 12 months for CCR 87464(f)(1). The same citation was issued on 11/19/25,

Type of visit: Case Management - Incident

On November 19, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case management visit to follow up on a case-management incident visit that was conducted on 11/12/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the visit. On 11/12/25, LPA conducted a visit to follow up on an incident that occurred on 10/24/25. The Licensee reported on 10/23/25, Resident 1 (R1) left the facility without signing out and did not come back overnight. On 10/24/25 at around 8:45am, the facility received a call from R1 stating that he/she is at Peninsula Medical Center due to rapid heart rate. According to the assistant administrator, he indicated that both him and the administrator observed R1 leaving the facility on 10/23/25 between 9am-10am. Both assistant administrator and administrator asked R1 where he/she was going and R1 indicated he/she was going to the doctors. Based on R1's file reviewed, R1's physician's report dated 6/13/25 indicates R1 is not allowed to leave the facility unassisted. Despite staff being aware that R1 was leaving, R1 still left the facility unassisted on 10/23/25. Based on information collected, there was an endorsement from the med-tech to the NOC shift caregivers that R1 is out. In addition, there was a text message sent to a group chat at 10:35pm by PM med-tech stating if R1 does not return back to the facility by 12am to call the police. The NOC shift caregivers have access to the phone so they were aware of the text message. There was no documentation provided to show that the police were called. According to the assistant administrator, PM Shift and NOC conduct safety checks every 2 hours. Assistant administrator indicated that NOC shift caregivers did not call 911 even though they were aware that R1 was not back at the facility. The NOC shift caregivers indicated they notified the assistant administrator, however he was not on shift during the time and the facility's protocol is to call 911 if there are any emergencies/incident. 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.the state’s words, verbatim · CDSS document, Nov 19, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 20, 2025

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: Based on R1’s file reviewed, R1 has is unable to leave the facility unassisted, however, despite staff being aware that R1 was leaving, R1 still left the facility unassisted on 10/23/25. In addition, R1 did not return back to the facility the same day and although NOC shift caregivers were aware, they did not call 911 to report this incident which poses an immediate health and safety risk to residents in carethe state’s words, verbatim · CDSS document, Nov 19, 2025

Plan of correction: Licensee/administrator shall conduct an in-service training regarding facility's protocols for reporting requirements when a resident is missing/still has not returned from outting. Training shall include, who to contact, documentation, who is responsible for following up. 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 and 11/12/25.

Type of visit: Case Management - Incident

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). 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.the state’s words, verbatim · CDSS document, Nov 12, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Nov 13, 2025

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: 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.the state’s words, verbatim · CDSS document, Nov 12, 2025

Plan of correction: 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. 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.

From the deficiency page — Deficiency type: Type A · Section cited: CCR87705(d) · Plan of correction due date: Nov 13, 2025

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 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.the state’s words, verbatim · CDSS document, Nov 12, 2025

Plan of correction: 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.

Type of visit: Case Management - Incident

On November 12, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced case- management visit in relation to an incident that occurred on 10/24/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported on 10/23/24, Resident 1 (R1) left the facility without signing out and did not come back overnight. On 10/24/25 at around 8:45am, the facility received a call from R1 stating that he/she is at Peninsula Medical Center due to rapid heart rate. During the visit, LPA reviewed R1's file, reviewed documentation and interviewed the assistant administrator. According to the assistant administrator, both him and the administrator observed R1 outside the facility between 9am-10am and R1 stated he/she was going to a doctor's appointment. According to the assistant administrator, sometimes R1 makes his/her own appointments and staff are unaware of R1's appointments unless the facility scheduled them. Staff are unaware if R1 actually went to the doctors. Based on R1's physician's report dated 6/13/25, R1 is not allowed to leave the facility unassisted. Based on documentation reviewed, there was an endorsement from the med-tech to the NOC shift caregivers that R1 is out. In addition, there was a text message sent to a group chat at 10:35pm by PM med-tech stating if R1 does not return back to the facility by 12am to call the police. The NOC shift caregivers have access to the phone so they were aware of the text message. There was no documentation provided to show that the police were called. According to the assistant administrator, PM Shift and NOC conduct safety checks every 2 hours so they would have been aware if R1 was not at the facility. Assistant administrator is unsure if NOC shift caregivers called 911 and if they did, why it was not documented. Further investigation is required. Report is reviewed with the assistant administrator and a copy is provided.the state’s words, verbatim · CDSS document, Nov 12, 2025

Allegation investigated: Facility has pests

On September 3, 2025, Licensing Program Analyst (LPA) Komal Curley conducted an unannounced 10-day complaint visit. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit. Regarding the allegation, facility has pests, according to the reporting party, the facility has mice and there are mice droppings in residents bedrooms and in the resident's drawers. During the visit, LPA interviewed staff, observed residents rooms and reviewed documents. LPA observed mouse traps in four resident rooms. According to staff, there were mice droppings in three resident rooms, however has been cleaned by housekeeping. According to the administrator, the pests started coming when the facility did not have garbage picked up from the facility for 3 weeks. Based on the pest-control invoices provided, the facility hired a third party pest control vendor, Orkin who has been coming to the facility once a week to inspect and service the facility. However, despite pest control coming to the facility once a week, the facility still has pests and the facility did not ensure the facility was free from pests. (continue to 9099C) Substantiated 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. A civil penalty of $250.00 is being assessed during the visit today for a repeat citation that was issued on 1/17/25 for California Code of Regulation, 87468.1(a)(2) Personal Rights of Residents in All Facilities. Report was discussed with Administrator, Paula Madrigal and a copy is provided with appeal rights. A copy of the civil penalty is also being provided to the administrator,the state’s words, verbatim · CDSS document, Sep 3, 2025 · control 14-AS-20250827123554

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Sep 4, 2025

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: Based on staff interviews, the pests started coming into the facility because there was no trash service for three weeks. Although, pest control is coming into the facility, the facility still has pests and the facility did not ensure the facility was free from pests which poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 3, 2025

Plan of correction: Licensee/administrator shall submit a plan in writing to ensure facility is free from pests. Plan should include increasing pest control services, in addition to other ways to ensure facility is free from pests. A civil penalty of $250.00 is being assessed during the visit today for a repeat citation that was issued on 1/17/25

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

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 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.the state’s words, verbatim · CDSS document, Aug 26, 2025 · control 14-AS-20250821094037

Type of visit: Case Management - Incident

On June 5, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occured on 5/26/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported on 5/26/25, Resident 1's (R1's) hand was inside of Resident 2's (R2's) clothes and was not bothered by it according to Resident 3 (R3) who was also the witness. All required parties were notified and facility assessed residents for any signs of injury or distress. During the visit, LPA interviewed the Assistant administrator, reviewed R1 and R2's file, and attempted to interview residents. LPA was unable to interview R2 and R3 as they were eating lunch in the dining hall. LPA interviewed R1 who denied touching R2. Based on file reviewed, R1's physician's report indicates that R1 does not have any cognitive impairments and/or inappropriate behaviors. The assistant administrator indicated that this incident is the first incident that has occurred with R1 being inappropriate to another resident at the facility. Based on R2's file reviewed, R2 has a diagnosis of dementia and does have inappropriate behaviors and is confused/disoriented. According to the assistant administrator, staff immediately intervened when R1 and R2 were observed together and redirected. No incidents between R1 and R2 have occurred since 5/26/25. An in-service training was provided to all staff after this incident. No citations are issued during the visit. Report is reviewed with Assistant Administrator and a copy is provided.the state’s words, verbatim · CDSS document, Jun 5, 2025

Allegation investigated: Staff touched resident inappropriately

On May 14, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced complaint visit to deliver the findings for the above allegation. LPA met with Assistant Administrator, Grabriel Mendoza and explained the purpose of the visit. Regarding the allegation, staff touched resident inappropriately, according to the reporting party, Resident 1 (R1), there has been two separate incidents where Staff 1 (S1) inappropriately touched R1's private parts. During the invesitgation, the Department reviewed R1's file, interviewed residents and staff. According to R1, during the evenings while S1 would change R1’s diaper, S1 used the palm of his/her hand to rub R1’s private part three separate times, however there were no witnesses the first two time and the third time there was another staff member (S2) present. According to S1 and S2, he/she denies this allegation. S2 indicated that R1 requires two staff assist as R1 is bedridden. In addition, S2 indicated that indicated R1 often accuses staff of hurting them when they are just trying to change R1’s diaper and clean up R1’s bowel movement. The Department concluded the investigation and there is no evidence to prove or disapprove that R1 was inappropriately touched by S1. Based on interviews conducted and 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 Assistant Administrator, Gabriel Mendoza and a copy is provided. Unsubstantiatedthe state’s words, verbatim · CDSS document, May 14, 2025 · control 14-AS-20241107162441

Type of visit: Case Management - Incident

On May 14, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 5/1/25. LPA met with Assistant Administrator, Gabriel Mendoza and explained the purpose of the visit. The Licensee reported, on 5/1/25, Staff 1 (S1) reported to the Administrator that Staff 2 (S2) was given cash by Resident 1 (R1) to fix R1's bed. S2 was immediately put on suspension pending facility's investigation. During the visit, LPA interviewed staff, reviewed R1's file, attempted to interview R1 and S2, and observed R1's bed. LPA was unable to interview R1 and S2 as they were not at the facility during the visit. According to R1's physician's report, R1 does not have any confused/disoriented behavior and is able to communicate needs, in addition to manage his/her own cash. According to staff interviewed, R1 reported to the staff that his/her bed was broken and staff immediately addressed it with the Assistant administrator and the administrator. According to the Assistant administrator and staff interviewed, it took 3 days for a third party vendor to fix R1's bed because R1 has a special geriatric bed and the facility needed to call a third party vendor to come fix it, however during those 3 days, R1 insisted to pay S2 to fix his/her bed. Because S2 couldn't fix the bed, S2 returned the money to R1. During the visit, LPA observed R1's bed fixed and in good working condition. An in-service training was immediately conducted the same day and another in-service training will be conducted on 5/16/25. No citations are issued during the visit. Report is reviewed with the Assistant administrator and a copy is provided.the state’s words, verbatim · CDSS document, May 14, 2025

Type of visit: Case Management - Other

On April 16, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit to follow up on an annual inspection that was conducted on 3/27/25. LPA met with Assistant Administrator, Grabriel Mendoza and explained the purpose of the visit. On 3/27/25, LPA observed a change of use in facility rooms, from resident rooms to staff rooms and built walls and doors. Facility did not provide a new floor plan to CCLD. During the visit today, LPA toured the facility with Co-administrator. Daly City Fire Inspector Aguon joined the visit today. No citations are issued during the visit. Report is reviewed with the assistant administrator and a copy is provided. --UPDATED facility floor plan shall be submitted to CCLD.the state’s words, verbatim · CDSS document, Apr 16, 2025

Type of visit: Required - 1 Year

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). 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.the state’s words, verbatim · CDSS document, Mar 27, 2025

Type of visit: Case Management - Incident

On February 11, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit regarding an incident that occurred on January 29, 2025. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit. On 1/29/25, the Licensee reported, Resident 1 (R1) eloped from the facility. At 10:30am, the Daly City Police Officer came to the facility to report that R1 was found on the street and that he/she fell out of his/her wheelchair and smelled like alcohol. The police had a hold on him and took him to the hospital. All required parties were notified. During the visit, LPA reviewed documents and interviewed administrator. LPA observed the resident sign-in and sign-out log located in front of the nurse's station. According to the log observed, R1 did not sign out when he/she left the facility. Administrator indicated that R1 left from the upstairs back door. Based on file reviewed, R1's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted. According to the Licensee, the med-tech on duty gave R1 his/her medication around 8:30am/9am in R1's bedroom, however after that staff did not observe R1 leave the facility. The facility failed to provide care and supervision as necessary to meet the needs of R1 which resulted into R1 eloping from the facility from the back door and resulting in R1 having a fall while in a wheelchair. 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 administrator and a copy is provided with appeal rights. A copy of the civil penalty is also provided with appeal rights.the state’s words, verbatim · CDSS document, Feb 11, 2025

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Feb 12, 2025

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: Based on file reviewed, Based on R1's physician's report, R1's physician's report dated 11/14/23 indicated R1 has a diagnosis of traumatic brain injury with cognitive dysfunction and can't leave the facility unassisted. According to administrator, staff did not observe R1 leave the facility. R1 did not have a staff escort R1 when leaving the facility.the state’s words, verbatim · CDSS document, Feb 11, 2025

Plan of correction: Licensee/Administrator will provide in-service training to all staff members regarding checking to ensure residents who are signing-out have a staff member escorting them if required. A repeat civil penaty is assessed today for a repeat violation within 12 months. Same violation was cited on 10/30/24. $1,000.00 civil penalty is provided on 2/11/25.

Allegation investigated: Staff did not ensure that facility was free from pests. Facility is unkempt. Facility is malodorous. Staff do not provide adequate laundry service.

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 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.the state’s words, verbatim · CDSS document, Jan 17, 2025 · control 14-AS-20241011094829

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87468.1(a)(2) · Plan of correction due date: Jan 18, 2025

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: 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.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87303(a) · Plan of correction due date: Jan 24, 2025

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: 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 odthe state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: 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.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87307(a)(3)(C) · Plan of correction due date: Jan 24, 2025

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: 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.the state’s words, verbatim · CDSS document, Jan 17, 2025

Plan of correction: 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.

Allegation investigated: Staff mismanaged resident's medication. Staff did not ensure centrally stored medication was inaccessible to residents

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 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.the state’s words, verbatim · CDSS document, Dec 26, 2024 · control 14-AS-20241219201154

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Dec 27, 2024

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: 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 carethe state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: The Licensee/Administrator shall provide a plan to ensure all medications and confidential documents are locked and inaccessible to residents in care. 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

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(h)(6)(C) · Plan of correction due date: Jan 2, 2025

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. 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 carethe state’s words, verbatim · CDSS document, Dec 26, 2024

Plan of correction: 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.

Type of visit: POC

On November 12, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced plan of correction (POC) visit to verify and to confirm that the facility is in compliance with the citation that was issued on 10/30/24. LPA met with General Manager, Judith MaCalisang and explained the purpose of the visit. On 10/30/24, the facility was issued a citation for California Code of Regulations (CCR) 87465(h)(2) Incidental Medical and Dental Care as LPA observed medications to be unlocked and accessible to residents in care. During the visit conducted today, LPA observed the medication carts located on the first floor at the nurses' station. LPA observed medications to be all locked and inaccessible to residents. LPA observed a gate that is locked when staff members are not present at the nurses' station. LPA observed the nurses' station on the second floor to have a new door lock. Medication cart on the second floor was observed repaired and locked. Deficiency is now verified as corrected and cleared. Report is reviewed with General Manager, Judith MaCalisang and a copy is provided.the state’s words, verbatim · CDSS document, Nov 12, 2024

Allegation investigated: Staff did not ensure centrally stored medication was locked and inaccessible to residents

On October 30, 2024, 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 ensure centrally stored medication was locked and inaccessible to residents, according to the reporting party, it was observed that the nurses' station gate was wide open with a clear view and access to residents' medication bottles. In addition, the reporting party indicated that the gate remained unlocked and open for 5-10 minutes until it was brought to a staff members attention. During the visit, LPA interviewed staff and observed the nurses' station on the first and second floor. Based on observations, LPA observed nurses' station gate on the first floor open and medication unlocked and accessible to residents. Medication bottles, medication in bubble packs, medication for destruction, and other prescribed medications were observed on top of the medication cart on the first floor. LPA observed the second floor nurses' station and observed medication cart to be unlocked with the key on it. In addition, LPA observed medication pills in a cup on top of the medication cart. At the time of the visit, no staff was observed present in the nurses' station on the second floor and the door was open. Furthermore, it was observed that the medication cart on the second floor is in disrepair and does not lock, and the room door stays unlocked at all times. Based on observations, and interviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation is 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 and a copy is provided with appeal rights. Substantiatedthe state’s words, verbatim · CDSS document, Oct 30, 2024 · control 14-AS-20241025084857

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(h)(2) · Plan of correction due date: Oct 31, 2024

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: Based on observations, LPA observed medications cart on the second floor to be in unlocked and in disrepair as it won't lock. Medication pills were observed on top of the medication cart to be accesible to residents. Medication cart on the first floor was observed unlocked with key attached to it; medication bottles, medication for destruction, medication in bubble packs, along with other prescribed medication were observed on top of the medication cart unlocked and accessible to residents which poses an immediate health risk to residents in care.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: The Licensee/Administrator shall provide a plan to ensure all medication carts and medications are locked and inaccessible to residents at all times and will provide a copy of the plan to CCL by 10/31/24

Type of visit: Case Management - Incident

On October 30, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit to follow up on an incident that occurred on 10/19/24. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit. The licensee reported, on 10/19/24 at approximately 10:00am, Resident 1 (R1) signed out of the facility to attend an AA meeting. R1 did not tell staff he/she was leaving and no staff was present at the nurses' station when R1 was signing out to leave the facility. Morning staff med-tech noticed that R1 had not returned back to the facility and notified evening staff, however evening staff did not check in to see if R1 returned back to the facility. Facility called 911 on 10/20/24 at 5:00am and the police department notified staff that R1 was detained. During the visit, LPA reviewed documents and interviewed administrator. LPA observed the resident sign-in and sign-out log located in front of the nurse's station. According to the log observed, R1 did sign out at 10am on 10/19/24 and it was noted that he/she was going to an AA meeting. Based on file reviewed, R1's physician's report dated 5/3/24 indicated R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. R1 previously left the facility unassisted on 9/24/24, and staff failed to call the police right away to ensure R1 was safe as when staff discovered R1 was not at the facility at 9:15pm, it was not till 11:15pm staff called the police. In-service training was provided to staff on 10/21/24 regarding doing rounds to ensure residents are in the facility and to ensure that if residents are unable to leave the facility unassisted, an escort will be provided to ensure safety of resident. The facility failed to provide care and supervision as necessary to meet the needs of R1 which resulted into R1 leaving the facility unassisted again. In addition, staff did not know where R1 was until the following morning when staff called the police and was told that R1 was in jail. The facility failed to call all required parties immediately when they observed R1 was not at the facility and the evening shift staff failed to check to see if R1 returned back. Deficiency was observed during the visit and cited from the California Code of Regulations, Title 22 and Health and Safety Code. See LIC809-D. An immediate civil penalty was assessed for Absence of supervision. Failure to correct the deficiency may result in additional civil penalty. Report is reviewed with Administrator and a copy is provided with appeal rights. A copy of civil penalty is also provided.the state’s words, verbatim · CDSS document, Oct 30, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 31, 2024

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: Based on interviews, due to the absence of supervision, R1 left the facility again unassisted on 10/19/24 and facility staff failed to check to see if R1 returned back to the facility knowing R1 left in the morning which poses an immediate health risks for residents in care. R1 did not return back to the facility till 10/29/24.the state’s words, verbatim · CDSS document, Oct 30, 2024

Plan of correction: The Licensee/Administrator will develop a plan to ensure residents are being supervised at all times. Administrator/licensee will provide a copy of the plan to CCL by 10/31/24. Immediate Civil Penalty of $500.00 is being assessed today 10/30/24 for absence of supervision.

Type of visit: Case Management - Incident

On October 14, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case-management visit in relation to an incident that occurred on September 23, 2024. LPA met with Administrator, Paula Madrigal and explained the purpose of the visit. On September 24, 2024, the Licensee reported that on September 23, 2024, Resident 1 (R1) signed out from the facility at 10:15am to go to his/her doctor's appointment. After the doctor's appointment, R1 called 911 due to the foot of his/her wheelchair getting stuck. Facility called 911 and filed missing persons at 11:15pm because R1 was observed not to be at the facility at 9:15pm when med-tech noticed. During the investigation, LPA reviewed documents and interviewed administrator. LPA observed the resident sign-in and sign-out log located in front of the nurse's station. According to the log observed, on 9/23/24, R1 signed out to go to a doctor's appointment at 9:45 am. Based on file reviewed, R1's physician's report dated 5/3/24 indicated R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. According to the administrator and staff interviewed, R1 has been going in and out of the facility without assistance for months. Based on interviews, it was indicated that on 9/23/24, R1 did not have a staff escort him/her to go out to the doctor's appointment because R1 has been doing it for months without staff accompanying him/her. Facility was unaware where R1 was as he/she did not have a cell phone for staff to reach R1 at. According to the administrator, it was not till 9:15pm when a staff noticed that R1 was not at the facility and not until 11:15pm when staff called the police for a missing person's. Nevertheless, facility failed to check in on R1 after his/her doctor's appointment and ensure R1 was safe as he/she was not back at the facility. In addition, facility failed to call the police right away when staff noticed that R1 was not back at the facility at 9:15pm. Deficiencies are cited under California Code of Regulations, Title, 22 cited on the LIC 809D. Failure to correct the deficiencies may result in civil penalties. Report was discussed with Administrator. A copy of this report and the Appeal Rights is provided.the state’s words, verbatim · CDSS document, Oct 14, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87464(f)(1) · Plan of correction due date: Oct 21, 2024

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) Violation of this regulation is not met as evidenced by: Based on file reviewed, Based on R1's physician's report, R1 has Mild Cognitive Impairment (MCI) and can't leave the facility unassisted. According to interviewes, on 9/23/24, R1 did not have a staff escort R1 to his/her doctor's appointment. According to the administrator, it was not till 9:15pm when a staff noticed that R1 was not at the facility and not until 11:15pm when staff called the police for a missing person's. Facility failed to ensure required parties were called immediately after noticing R1 was not at the facility.the state’s words, verbatim · CDSS document, Oct 14, 2024

Plan of correction: Licensee/Administrator will provide in-service training to all staff members regarding checking to ensure residents who are signing-out have a staff member escorting them if required.

Type of visit: Case Management - Incident

On September 10, 2024, Licensing Program Analyst (LPA) Komal Charitra conducted a follow-up case management in relation to the case management visit that was conducted on 8/20/2024. LPA met with Administrator, Paula Madrigal, and explained the purpose of the visit. On August 9, 2024, the facility reported to the Department that on August 8, 2024, resident #1 (R1) reported that staff #1 (S1) bended his/her fingers and S1 slapped his/her face. During the visit, LPA discussed the incident with Paula, reviewed S1's training records, interviewed R1, and interviewed witness (S2). According to R1, S1 bent R1's fingers and slapped R1 after R1 refused to be changed. R1 indicated there was another staff member present but did not remember who it was. In addition, R1 indicated that he/she did report it to a nurse but did not remember the nurse's name. LPA interviewed S2 who indicated that he/she was with S1 during the time of the incident and did not observe any physical abuse. In addition, according to S1, he/she stated they were aware of the abuse complaint filed against him/her but denied allegations and indicated he/she did not do it. Based on the incident report, an assessment was done on R1 and there were no bruising, swelling noted. In addition, there were no complaints of pain. LPA reviewed S1 and S2's training record and observed that it was up to date. Facility administrator provided additional abuse training on 8/8/2024 after this incident occurred. According to the administrator, this is the first complaint of abuse that was filed against S1. No deficiencies were issued during this visit. LPA reviewed the report with Administrator, Paula Madrigal. A copy is provided by email due to technical issues with printer.the state’s words, verbatim · CDSS document, Sep 10, 2024

Type of visit: Case Management - Incident

On August 20, 2024, Licensing Program Analyst (LPA), Murial Han conducted an unannounced case management visit to follow-up on an incident that was reported by the facility. LPA met with manager, Judith MaCalisang and explained the purpose of today's visit. On August 9, 2024, the facility reported to the Department that on August 8, 2024, resident #1 (R1) reported that staff #1 (S1) bended his/her fingers and S1 slapped his/her face. During today's visit, LPA collected documents. No deficiency is cited today. This report is reviewed and discussed with the manager. A copy is provided.the state’s words, verbatim · CDSS document, Aug 20, 2024

Allegation investigated: Staff are not ensuring resident is taking medication as prescribed.

On July 23, 2024, Licensing Program Analyst (LPA), Murial Han conducted a 10-day complaint visit. Upon entrance, LPA met with Medication Technician, Ivy Hautea and explained the purpose of the visit. Momentarily, Medication Technician, Authur Santos and the Manager, Judith MaCalisang arrived and assisted with the visit. Regarding to the allegation of- staff are not ensuring resident is taking medication as prescribed, the reporting party stated resident #1 (R1) disclosed that staff has been providing medication four times a day but he/she been only taking two pills and storing the other two pills. As part of the investigation, LPA interviewed the facility manager who stated that R1 is no longer residing at the facility and acknowledged that sometimes staff leaves resident's medications on resident's trays instead of ensuring all the medication is taken by the residents. In addition, the facility manager stated that the facility is working with the staff to improve the medication administration process. Substantiated LPA interviewed 5 residents and 3 of them reported that staff did not ensure they take their medications as they would just leave it on their meals trays, and/or their bedside table. After the investigation, this allegation is deemed to be substantiated. Based on observations, interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was 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. The report is reviewed and discussed with the manager; a copy is provided with the Appeal Rights.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 14-AS-20240718152306

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87411(d)(4) · Plan of correction due date: Jul 24, 2024

87411 Personnel Requirements - General..(d)All personnel shall be given on the job training or have related experience in the job assigned to them..(4) Knowledge required to safely assist with prescribed medications which are self-administered. This requirement is not met as evidenced by based on observations, interviews and record reviews the facility staff did not ensure residents take their medications during medication administration times which poses an immediate health and safety risks to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff education. The administrator/licensee will submit a copy of the plan to CCL by 7/24/2024.

Allegation investigated: Staff are not maintaining a complete record for residents.

On July 23, 2024, Licensing Program Analyst (LPA), Murial Han conducted a 10-day complaint visit. Upon entrance, LPA met with Medication Technician, Ivy Hautea and explained the purpose of the visit. An additional Medication Technician, Authur Santos and the Manager, Judith MaCalisang arrived momentarily and assisted with the visit. Regarding to the allegation of- staff are not maintaining a complete record for residents, the reporting party stated that the doctors have observed the Medication Administration Records (MARs) for resident #1 (R1) and resident #2 (R2) were incomplete or missing altogether. As part of the investigation, LPA reviewed the MARs for R1 and R2 and interviewed facility's staff members. Based on the documents provided, LPA observed many omissions on R1 and R2's MARs for May and July, 2024 on different shifts and there was no explanations as to why the medication was not administered. Substantiated According to the facility's Medication Technicians (Med Techs) and the manager, there should not be omissions on the MARs and the Med Techs should document on the MAR the reason that the medication was not administered. After the investigation, this allegation is deemed to be substantiated. Based on observations, interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegation was 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. The report is reviewed and discussed with the manager; a copy is provided with the Appeal Rights.the state’s words, verbatim · CDSS document, Jul 23, 2024 · control 14-AS-20240716115017

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465(a)(6) · Plan of correction due date: Jul 30, 2024

87465 Incidental Medical and Dental Care..a)A plan for incidental medical and dental care shall be developed by each facility...(6)When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by based on observation, record review and interview, facility did not ensure R1 and R2's MARs were completed which posed a potential health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Jul 23, 2024

Plan of correction: The administrator/licensee will develop a plan to ensure compliance and the plan shall include staff education. The administrator/licensee will submit a copy of the plan to CCL by 7/30/2024.

Type of visit: Case Management - Annual Continuation

On 04/12/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - annual continuation visit in order to review the files of both residents and staff in the facility. LPA met with administrator Juliet Pacaldo and explained the purpose of today's visit. During today's visit LPA reviewed 5 resident files and 5 staff files in order to ensure they are current and up to date. Per files reviewed all files were complete and contained the required documents. The facility does not handle resident cash resources or physical monies. Facility conducts regular disaster and fire drills accordingly last conducted 01/02/2024. The following updated forms are being requested to be received by 04/19/2024: • LIC610D Emergency Disaster Plan • LIC 308 Designation of Administrative Responsibility • LIC 500 Personnel Report • Updated administrator certificate • LIC9020 Client Roster • Certificate of Liability Insurance No citations issued. Report is reviewed with administrator Juliet Pacaldo.the state’s words, verbatim · CDSS document, Apr 12, 2024

Type of visit: Required - 1 Year

On 02/26/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required 1 year annual inspection visit. LPA met with administrator Juliet Pacaldo and explained the purpose of today's visit. This is a two level facility. Annual Fees are current. The physical plant was toured inside and outside to ensure the safety of the residents. LPA observed the facility kitchen which is clean and observed appliances are in good repair. Knives are stored in the kitchen not accessible to resident. Cleaning solutions are also locked. Perishable and non-perishable food items are observed as in place. LPA observed the medications as in place and not accessible to residents. The first aid kit observed as complete with required items. LPA observed that the facility is equipped with full sprinkler system, fire extinguishers are placed through out the facility, smoke detector/carbon monoxide detectors are observed in place, and central heating system. PPE and additional food supplies are observed as in place in the garage. Laundry area is also observed as fully operational. Emergency exit routes are observed inside and outside to be free and clear of obstructions. LPA observed several resident rooms at random and all rooms appeared clean, free of odors, and contained all the required furniture per regulatory recommendations. Cleaning supplies are observed locked and not accessible to resident. COVID PPE and resident incontinence supplies are observed in place. This annual inspection be continued at a later date. Report is reviewed with Juliet. No citations issued.the state’s words, verbatim · CDSS document, Feb 26, 2024

Type of visit: Case Management - Incident

On this day, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced case management - incident visit in response to a possible gas leak reported to the Department on 12/20/2023. LPA met with LVN Judith Macalisong and explained the purpose of today's visit. On 12/20/2023, the facility was alerted of the smell of gas coming from the facility. Local PG&E and fire department was notified of the smell and inspections were made. It was found out that the source of the gas leak was a broken water heater component from one of the two water heaters the facility is equipped with. The water heater in question is located in a mechanical room at the exterior of the facility adjacent to the activity room on the east side of the facility. During today's visit LPA toured the facility and took water temperatures in two locations. LPA tested the water as 115F and 118F. LPA observed the new water heater components in place as well as the water heater. The facility reported no shortages during the evening hours of 12/20/2023. The facility had warm water, heating, and ability to cook meals. The gas supply to the facility was not shut off. The repairs were made on 12/21/2023 before noon time according to the licensee Juliet Pacaldo. No citations are issued. Report is reviewed with Judith.the state’s words, verbatim · CDSS document, Dec 22, 2023

Allegation investigated: - Facility is in financial distress.

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to investigate further the allegations received and deliver findings. LPA met with assistant administrator April Pacaldo and explained the purpose of today's visit. During the course of the investigation LPA conducted interviews, reviewed documents, and made observations through out the facility. Documents reviewed showed that bills, pay checks, and the facility as a whole has enough money to operate. Statements reviewed showed the incoming and outgoing items paid out as part of the facility operation. This allegation is unfounded. This agency has investigated the complaint alleging, Facility is in financial distress. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Unfoundedthe state’s words, verbatim · CDSS document, Dec 12, 2023 · control 14-AS-20230308102358