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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601135
Report Date: 09/30/2024
Date Signed: 09/30/2024 01:54:55 PM

Document Has Been Signed on 09/30/2024 01:54 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:SAINT JARRIELLE RESIDENTIAL CAREFACILITY NUMBER:
415601135
ADMINISTRATOR/
DIRECTOR:		UY, NANCYFACILITY TYPE:
740
ADDRESS:675 CRESPI DRIVETELEPHONE:
(650) 355-6173
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 5CENSUS: 0DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Jacquelyn Melosantos, LicenseeTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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On 9/30/2024, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility. Upon arrival, LPA found that there weren't any vehicles or signs of any individuals present at the facility. LPA rang the doorbell and verbally made presence and purpose of visit known but received no answer. LPA proceeded by contacting Licensee, Jacquelyn Melosantos by telephone. During conversation, LPA was informed by the Licensee that the facility was under lease but had been sold within the year. LPA was informed that the home owner had previously expressed wanting to sell the facility and cease operation. Licensee indicated that all residents had been safely relocated approximately 6 months ago and have not admitted any other residents since, as the Licensee was awaiting homeowner's determination.

Licensee stated that as of approximately 6 months ago, the facility has not been in operation but still continues to hold the license. LPA and Licensee discussed the process of either closing the facility and reapply, or continue paying for license and notify the department once a change of location is determined. LPA confirmed that there are no residents in care and that the facility is not currently in operation. The Licensee was not available for signatures but an electronic copy was provided for review and signatures requested.

No deficiencies cited during today's visit.
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: Dominic Tobola
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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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