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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601163
Report Date: 10/29/2025
Date Signed: 11/03/2025 06:04:46 PM

Document Has Been Signed on 11/03/2025 06:04 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: 4DATE:
10/29/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Caregiver, Gloria RodrinTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/29/2025, Licensing Program Analyst (LPA) Murial Han conducted an unannounced case management visit to follow-up with the observations while conducting the 10-day complaint visit, LPA met with caregiver, Gloria Rodrin and explained the purpose of the visit. The administrator was contacted by the caregiver via phone.

During the complaint visit ( 14- AS-20251020093609), LPA observed Staff #1(S1) was assisting residents and staff #2(S2) came into the facility from the garage. LPA checked S1 and S2's personnel records and observed S2 did not have a criminal record transfer.

LPA interviewed the administrator who stated that S2 is a gardener and S2 started working at facility 2 days ago,

LPA interviewed S1 who stated that S2 started working at the facility since last Thursday.

LPA interviewed S2 who stated that he/she started working at the facility yesterday.

LPA interviewed resident #1 (R1) who stated that S2 has been working at the facility for a few months.

During the visit, LPA observed S2 was working in the kitchen and resident was calling S2's name for assistance but S2 stopped working when it was observed by LPA that he/she did not have a criminal record transfer.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2025
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: 10/29/2025
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In addition, LPA observed staff #3(S3) who worked twice a week did not have criminal record clearance nor a criminal record transfer and according to the administrator, S3 has been working at the facility since 2024.

During today's visit, LPA also observed the TV in the living room was not able to play any channels. S1 was able to turn on the TV but there was no channels. According to Resident #2 (R2), the TV has not been working for months.

A civil penalty in the amount of $1500 is being assessed today; $500 for no criminal record clearance for S3 and $1000 for no criminal record transfer for S2 and S3.

Deficiency is cited under California Code of Regulations, Title, 22 cited on the LIC 809D.
Failure to correct the deficiencies may result in additional civil penalties.

This report is reviewed and discussed with caregiver and administrator over the phone.. A copy of this report and the appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Murial Han
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 11/03/2025 06:04 PM - It Cannot Be Edited


Created By: Murial Han On 10/29/2025 at 12:54 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: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2025
Section Cited
CCR
87355(e)

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87355 Criminal Record Clearancee (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility:
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The administrator stated that S3 will be removed from duty until criminal background and transfer processes are completed. The Licensee will provide a plan of correction indicating the process and the date to complete S3's criminal background process. The POC will indicate the facility's staffing plan to ensure sufficient
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This requirement is not met as evidenced by based on observation, record review and interview, S3 has been working at the facility since 2024 without a criminal record clearance which poses an immediate health and safety risks to residents in care.
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staffing at all times. The POC shall also include what is the facility's process to ensure this does not happen again. The licensee will provided a copy of the plan and a copy of an updated LIC500 to CCL by 10/30/2025.
A civil penalty of $500 is being assessed today.
Type A
10/30/2025
Section Cited
CCR83755(e)(3)

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87355 Criminal Record Clearancee (e) All individuals subject to a criminal record review... shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance.. This requirement is not
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The licensee will submit a plan of correction indicating what is the facility's plan to ensure S2 and S3 will complete the transfer of a criminal record clearance process and the date of completion. The plan of
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met as evidenced by based on observation, record review and observation, S2 and S3 did not have a transfer of criminal record clearance which poses an immediate health and safety risk to residents in care.
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correction shall include the plan to ensure this does not happen again. The Licensee will provide a copy of the plan of correction by 10/30/2025.
A civil penalty of $1000 is being assess for S2 and S3.
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:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 11/03/2025 06:04 PM - It Cannot Be Edited


Created By: Murial Han On 10/29/2025 at 01:29 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: 10/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2025
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. This requirement is not met as evidenced by:
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The licensee will submit a plan of correction indicating the plan to ensure the TV in the living will be in good working condition and will submit a copy of the plan to CCL 11/10/2025.
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Based on observation, and interview, the TV in the living was not been working for months which poses a potential health and safety risk to residents in care.
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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:
Murial Han
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/29/2025


LIC809 (FAS) - (06/04)
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