380504134-6-30-2025-14-AS-DTOA-DJ5QYD-20250630123457

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 380504134
Report Date: 06/30/2025
Date Signed: 06/30/2025 12:35:48 PM

Document Has Been Signed on 06/30/2025 12:35 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:	JULIE'S CARE HOME		FACILITY NUMBER:	380504134
ADMINISTRATOR/ DIRECTOR:	CHAE, JULIE		FACILITY TYPE:	740
ADDRESS:	1363 - 5TH AVENUE		TELEPHONE:	(415) 566-4527
CITY:	SAN FRANCISCO	STATE: CA	ZIP CODE:	94122
CAPACITY: 14	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	06/30/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Sarah Chu, Administrator & Luz Madraga, Caregiver		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 6/30/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Caregiver, Luz Madraga. Administrator, Sarah Chu was contacted and arrived later in the visit. The facility currently provides care for 5 residents none of which with a diagnosis of dementia. LPA continued with a tour of the facility with staff, facility found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers located throughout the facility were found to be charged. Smoke and carbon monoxide detectors were present. LPA also observed two new carbon monoxide detectors that the Licensee will be installing on both facility floors. Emergency disaster plan is reviewed and completed. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations, with food stored in the kitchen refrigerator found to have appropriate coverings, enough for residents in care. There was a supply of hygiene products and paper products available for residents. Resident's bedroom have lighting & appropriate furnishings and bedding items. Restrooms for resident use were equipped with non-slip mats, grab bars and kept in good condition. There is a large outdoor patio equipped with appropriate shading for resident use. Medications are stored in designated cabinets in the kitchen and were found to be secured. Continued onto LIC809-C

April Cowan	TELEPHONE: (650) 416-9499 -
Dominic Tobola	TELEPHONE: (650) 393-9128
	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

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: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
	VISIT DATE: 06/30/2025

NARRATIVE

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Upon spot review of medications, LPA found that the facility has centrally store medication records updated and in order. LPA conducted a sample file review for residents and found all items to be current. Upon a sample review of staff files LPA found that all caregiver staff have health screening records on file and training records on track for completion. LPA found that 2 of 3 staff require updated 1st aid certification but are scheduled to complete training. Technical Violation issued. Lastly, during the inspection, LPA observed several mediations belonging to staff found in an unsecured drawer. The items were immediately removed and stored in staff bedroom. Deficiency cleared at the time of visit.

Sarah Chu's Administrator Certificate 6076000740 is valid through 2/26/2027.

LPA requested the following documents be sent to CCL by COB 7/14/2025:
LIC 308 Designated Facility Responsibility LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

SUPERVISOR'S NAME: April Cowan	TELEPHONE: (650) 416-9499 -
LICENSING EVALUATOR NAME: Dominic Tobola	TELEPHONE: (650) 393-9128
LICENSING EVALUATOR SIGNATURE:	DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/30/2025 12:35 PM - It Cannot Be Edited

Created By: Dominic Tobola On 06/30/2025 at 12:28 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: JULIE'S CARE HOME	FACILITY NUMBER: 380504134
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/30/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

Storage Space and Access

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above in several medication found in unsecured drawer, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/30/2025
	Plan of Correction
1 2 3 4	Medications and any other items posing a risk to residnets in care were immidiately removed and placed in secured staff bedroom during visit. Deficiency cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

TELEPHONE: (650) 416-9499 -

	Dominic Tobola
NAME OF LICENSING PROGRAM ANALYST:

TELEPHONE: (650) 393-9128

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/30/2025

LIC809 (FAS) - (06/04)

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