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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601135
Report Date: 09/06/2022
Date Signed: 09/06/2022 02:12:13 PM

Document Has Been Signed on 09/06/2022 02:12 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
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:SAINT JARRIELLE RESIDENTIAL CAREFACILITY NUMBER:
415601135
ADMINISTRATOR:UY, NANCYFACILITY TYPE:
740
ADDRESS:675 CRESPI DRIVETELEPHONE:
(415) 424-7903
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 5CENSUS: 5DATE:
09/06/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Caregiver, Elizabeth HuligangaTIME COMPLETED:
02:20 PM
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On 9/6/2022 at 12:50pm, Licensing Program Analyst (LPA) Murial Han met with caregiver, Elizabeth Huliganga to conduct an unannounced Pre-Licensing inspection for a change of ownership. LPA Han was properly screened for COVID-19 at entry point. The Licensee Jacquelyn Melosantos arrived shortly thereafter and assisted with the rest of the inspection.

LPA toured the facility's building and grounds and observed the indoor and the outdoor passageways are free of obstruction. LPA observed proper postings around the facility. This is a single story facility with 4 bedrooms (3 private rooms and 1 semi-private rooms and 1 staff room) and 2 bathrooms. The residents bedrooms are observed to be cleaned and tidy. There are 5 residents and two staff present during the visit. The beds in the semi-private room observed to be 6ft apart. The facility is observed to be in good repair, clean, and odor-free. There is good lighting and the temperature measured at 76 degrees.

LPA observed disinfectants, chemicals, medications, and toxins are locked and inaccessible to residents.

LPA inspected the kitchen and dining room area. Both fresh food and frozen food supplies are observed to be sufficient. Dry goods/emergency food supplies are stored in the storage room. Dining room area is observed as clean and in order. Chairs are in place and there are two residents present during the inspection.

LPA inspected the water temperature in both bath/shower rooms, and kitchen and they measured at 116-118 degrees. All bath/shower rooms were observed to be equipped with grab bars, non-skid mats, hand washing signs, liquid soap, and paper towels.

Comp III orientation was given to Licensee, Jacquelyn Melosantos.

Pre-Licensing is now complete. Immediate Licensure is recommended pending final approval from the Central Applications Bureau.

Exit interview conducted with licensee.

A copy of the report is provided.
SUPERVISORS NAME: Jackie Jin
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE: DATE: 09/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/06/2022
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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