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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601163
Report Date: 06/13/2025
Date Signed: 06/13/2025 01:16:56 PM

Document Has Been Signed on 06/13/2025 01:16 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 JARIELLE RESIDENTIAL CARE 2FACILITY NUMBER:
415601163
ADMINISTRATOR/
DIRECTOR:		UY, NANCYFACILITY TYPE:
740
ADDRESS:768 LUNDY WAYTELEPHONE:
(650) 557-1227
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 3DATE:
06/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:John Guintu, CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 6/13/2025, Licensing Program Analyst (LPA) Tobola conducted an unannounced Annual Required – 1 yr. inspection for this facility and was greeted by Lead Caregiver, John Guintu. Licensee, Nancy Uy was notified of the visit but was not able to attend. The facility currently provides care for 3 residents none of which with a current 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 in the kitchen was found to be charged. Smoke detector were observed in resident bedrooms tested. LPA observed a carbon monoxide detector in the hallway to be non-functioning and in need of replacement.

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. LPA conducted a sample file review for residents found that 2 of 3 residents do not have physician's reports on file and 1 of 3 residents does not have a needs & service plan on file. Upon a sample review of staff files LPA found that 1 of 2 caregiver staff do not have current 1st aid & CPR certification on file. Upon interview with resident (R1), it was stated that the facility staff do not provide any supplies for activities or engagement. LPA observed an unplugged television in R1's room and found that the television is not connected to basic television channels compared to other residents in care. R1 stated that they aren't encouraged to participate in any exercise or activities while under the facility care.
Continued onto LIC809-C
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/13/2025
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: SAINT JARIELLE RESIDENTIAL CARE 2
FACILITY NUMBER: 415601163
VISIT DATE: 06/13/2025
NARRATIVE
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LPA will return at a later date for the purpose of an annual continuation visit to review medications, staff training and emergency response records.

Administrator, Nancy Uy is in the process of updating their administrator certification
Acting Administrator, Joanna Casandra Uy's administrator certificate 7035656740 is valid through 9/29/2026

LPA requested the following documents be sent to CCL by COB 6/20/2025:
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.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Dominic Tobola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2025 01:16 PM - It Cannot Be Edited


Created By: Dominic Tobola On 06/13/2025 at 12:34 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: SAINT JARIELLE RESIDENTIAL CARE 2
FACILITY NUMBER: 415601163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.311
Regulations
Every residential care facility for the elderly shall have one or more carbon monoxide detectors in the facility that meet the standards established in Chapter 8 (commencing with Section 13260) of Part 2 of Division 12. The department shall account for the presence of these detectors during inspections.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA observation, the licensee did not comply with the section cited above in 1 out of 1 carbon monoxide detectors not in functioning order, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee failed to ensure carbon monoxide detector was in functioning order. Licensee agrees to repair or replace carbon monoxide detector submit LIC9098 Proof of Corrections form indication correction has been completed. LIC9098 to be submitted to CCLD by POC date 6/20/2025.
Type B
Section Cited
CCR
87411(c)(1)
Personnel Requirements - General
(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above finding that 1 of 2 staff present did not have current 1st aid & CPR training on file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee failed to ensure all staff have received appropriate first aid training on file. Licensee agrees to ensure all caregiver staff have updated 1st aid training on file. Copies of completed certification to be submitted to CCL by POC date 6/20/2025.
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:
Dominic Tobola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/13/2025 01:16 PM - It Cannot Be Edited


Created By: Dominic Tobola On 06/13/2025 at 12:34 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: SAINT JARIELLE RESIDENTIAL CARE 2
FACILITY NUMBER: 415601163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87219(j)
Planned Activities
(j) The licensee shall provide sufficient equipment and supplies to meet the requirements of this section, including access to variety of reading materials. Special equipment and supplies necessary to reasonably accommodate the individual physical persons and mental needs of residents shall be provided as appropriate.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview with resident (R1), the licensee did not comply with the section cited above with R1 indicating a lack of activities, engagement and a non-operating activity supply (basic television) services, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee failed to ensure resident in care has sufficient equipment for activities and engagement. Licensee agrees to provide R1 with supplies that encourage engagement and activity. Licensee agrees to provide R1 with similar activity accommodation as other residents such as basic television channel access.
Type B
Section Cited
CCR
87458(c)
Medical Assessment
(c) The medical assessment shall include, but not be limited to:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in 2 out of 3 resident physician's reports not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee failed to ensure resident medical assessments (physician's reports: LIC602) are updated and on file. Licensee agrees to obtain updated medical assessments for residents (R1 & R2). Copies of LIC602 to be submitted to CCLD by POC date 6/2022025.
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:
Dominic Tobola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 06/13/2025 01:16 PM - It Cannot Be Edited


Created By: Dominic Tobola On 06/13/2025 at 12:34 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: SAINT JARIELLE RESIDENTIAL CARE 2
FACILITY NUMBER: 415601163

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(a)
Reappraisals
(a) The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated, in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101, Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA record review, the licensee did not comply with the section cited above in 1 out of 3 resident needs & service plan/appraisals not on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/20/2025
Plan of Correction
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Licensee failed to ensure all residents have updated needs & service plan/appraisals (LIC625) on file. Licensee agrees to complete LIC625 and submit copy to CCLD by POC date 6/20/2025.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:
Dominic Tobola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/13/2025


LIC809 (FAS) - (06/04)
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