415601163-12-15-2025-14-AS-BCHN-DQAAQ7-20260112232503

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601163
Report Date: 08/26/2025
Date Signed: 12/15/2025 01:03:03 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/18/2025 and conducted by Evaluator Yi Sam Jian

COMPLAINT CONTROL NUMBER: 14-AS-20250618092722

FACILITY NAME:	SAINT JARIELLE RESIDENTIAL CARE 2		FACILITY NUMBER:	415601163
ADMINISTRATOR:	UY, NANCY		FACILITY TYPE:	740
ADDRESS:	768 LUNDY WAY		TELEPHONE:	(650) 557-1227
CITY:	PACIFICA	STATE: CA	ZIP CODE:	94044
CAPACITY:	6	CENSUS: 3	DATE:	08/26/2025
		UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Gloria Rodrin		TIME COMPLETED:	01:16 PM

ALLEGATION(S):

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-Staff physically abused resident

INVESTIGATION FINDINGS:

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THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 08/26/2025.

On 08/26/2025, LPA conducted an unnannounced continue complaint investigation into the allegation that staff member S2 physically abused resident R1. LPA met with staff Gloria Rodrin(S1), LPA explained the purpose of the visit. LPA spoke with Administrator, Nancy Uy, who stated that she could not make the visit and gave permission for Staff S1 to sign required paperwork.

LPA conducted interviews, and reviewed documentation during the visit. CONT. TO 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20250618092722

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/26/2025

NARRATIVE

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THIS IS AN AMENDED REPORT FROM AN ORIGINAL REPORT DATED 08/26/2025.

Resident R1 reported that staff S2 had pushed R1 and handled R1 roughly. R1 also stated that S2 returned to the facility briefly after being terminated but has not been seen since. No witnesses or physical evidence were provided to corroborate the allegation, and no injuries were reported or observed.

The alleged incident occurred in the bathroom with only S2 and R1 present. No other residents were interviewed, as they were not witnesses to the event. Administrator stated that S2 had worked at the facility for approximately six months and that no prior complaints had been made against S2. Administrator reported no visible injuries or unusual bruising on R1 at the time of the alleged incident and S2 denied the accusation when interviewed by administrator. Administrator reported that no incident report was filed regarding the alleged incident.

Although the above investigations may have happened or are valid, based on the information obtained through interviews and record review, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED. This report is reviewed and discussed with staff S1. A copy is provided.

SUPERVISORS NAME: Brenda Chan
LICENSING EVALUATOR NAME: Yi Sam Jian
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2025

LIC9099 (FAS) - (06/04)

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