415601163-1-15-2026-14-AS-BCHN-DR235A-20260205165623

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415601163
Report Date: 01/15/2026
Date Signed: 01/15/2026 11:02:57 AM

Substantiated

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
10/20/2025 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20251020093609

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: 5	DATE:	01/15/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Alice Monton		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not have planned activities

INVESTIGATION FINDINGS:

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Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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

LIC9099 (FAS) - (06/04)

Page: 1 of 7

Control Number 14-AS-20251020093609

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/15/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/22/2026 Section Cited CCR 87219(a)	1 2 3 4 5 6 7	87219 Planned Activities (a) Residents shall be encouraged to maintain and develop their quality of life through participation in a variety of planned activities....	1 2 3 4 5 6 7	The administrator/licensee will develop a plan of correction to ensure the facility has variety of activities for residents. The plan of correction shall include the details of when and who is responsible to conduct the activities.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by based on observation, record review, and interviews, the facility does not have planned activities which poses a potential health and safety risk to residents in care.	8 9 10 11 12 13 14	The administrator will provide a copy of the plan of correction to CCL by 1/22/2026.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 2 of 7

Control Number 14-AS-20251020093609

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: 01/15/2026

NARRATIVE

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LPA interviewed the administrator and S1 and neither could provide details pertaining to the activities that the facility has for the residents.

During the 10-day complaint visit, LPA did not observe any activities at the facility and LPA observed the TV was broken (The facility was cited on 10/29/2025 and the TV has been replaced).

The State Official also reported that during his/her visits, there were no activities at the facility.

After the investigation, this allegation is deemed to be substantiated.

Based on interviews and record reviews during the investigation, the preponderance of evidence standard has been met. Therefore, this allegations were determined to be substantiated. Deficiencies of the California Code of Regulations, Title, 22 cited on the LIC9099-D. Failure to correct the deficiencies may result in civil penalties.

Report was discussed with caregiver and the administrator who was on the phone.

A copy of the report and the appeal rights were provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 7

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
10/20/2025 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20251020093609

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: 5	DATE:	01/15/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Alice Monton		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Due to lack of staff, resident is not able to get out of bed
Due to lack of supervision, resident went into another resident's room during the night

INVESTIGATION FINDINGS:

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On January 15, 2026, Licensing Program Analyst (LPA) Murial Han conducted an unannounced visit to deliver the findings of a complaint investigation. LPA met with caregiver, Alice Monton and explained the purpose of today's visit. The caregiver called and informed the administrator of LPA's visit.

Regarding the allegation of- due to lack of staff, resident is not able to get out of bed. The reporting party stated that resident in question (R1) want to get out of bed and transfer to a wheelchair for some fresh air but due to lack of staffing, R1 was not able to do so.

As part of the investigation, LPA interviewed R1, resident #2 (R2) and staff (S1).

LPA interviewed R1 who stated that he/she preferred to stay in bed because R1 could not walk at this time. R1 also stated that he/she did not trust the facility staff to transfer him/her into a wheelchair as they were not therapists. R1 stated that he/she did not want to risk falling during the transfer as he/she fell many times in the past that resulted in R1 being on the floor for hours before he/she got help. R1 stated that his/her needs are being met at the facility and staff members were providing good care.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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

LIC9099 (FAS) - (06/04)

Page: 4 of 7

Control Number 14-AS-20251020093609

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: 01/15/2026

NARRATIVE

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LPA interviewed resident # 2 (R2) who stated that staff are assisting and providing the care that R2 is required.

LPA interviewed staff #1 (S1) who stated that they offered R1 to get out of bed but R1 did not want to due to R1's physical condition.

After the investigation, this allegation is deemed to be unsubstantiated.

Regarding the allegation of- due to lack of supervision, resident went into another resident's room during the night, the reporting party stated that resident #3 (R3) enter R1's room at night, covering R1 with a blanket which resulted R1 being scared and panicking.

As part of the investigation, LPA interviewed R1, R2, and S1.

According to S1, when the incident happened, R1 and R3 were roommates so R3 did not enter another resident's room and R3 thought R1 was cold so R3 walked over to R1’s bed and covered R1 with a blanket. S1 stated that after the incident, they moved R3 to another room and there were no further incidents.

According to R1, S1 was present when it happened and S1 redirected R3 to another room. R1 stated that he/she was scared but it did not happen again after R3 was transferred to another room.

According to R2, R3 never entered his/her room and there were always staff members at the facility.

After the investigation, this allegation is deemed to be unsubstantiated.

Although the above investigations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Report was discussed with caregiver and the administrator who was on the phone.

A copy of the report was provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 7

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
10/20/2025 and conducted by Evaluator Murial Han

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20251020093609

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: 5	DATE:	01/15/2026
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Caregiver, Alice Monton		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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Staff did not ensure that resident hygiene needs are met
Reporting requirements

INVESTIGATION FINDINGS:

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Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

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

LIC9099 (FAS) - (06/04)

Page: 6 of 7

Control Number 14-AS-20251020093609

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: 01/15/2026

NARRATIVE

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LPA interviewed S1 who stated that they offered R1 to take a shower but R1 preferred to have sponge baths in bed, and they provided that several times a week.

During the 10-day complaint visit on 10/19/2025, R1 appeared to be cleaned and well-groomed.

After the investigation, this allegation is deemed to be unfounded.

Regarding the allegation of Reporting Requirement- the reporting party stated that resident #3(R3) went into R1's room and covered R1 with a blanket up to R1's and this incident was not reported to CCL.

As part of the investigation, LPA interviewed the administrator and S1.

The administrator stated that R1 and R3 were sharing a room and R3 thought R1 was cold so R3 went to R1's bed and covered R1 up to the neck. The administrator stated that they did not report it to CCL because it was not a reportable incident and there was no injuries to both residents. The administrator stated they moved R3 to another room after the incident and there were no further incidents.

LPA interviewed S1 who stated that she was present when this happened and R3 was concerned that the roommate (R1) was cold so R3 covered R1 with a blanket and R1 got scared. S1 stated that R3 was moved to another room right away and both residents were fine afterwards.

After the investigation, this allegation is deemed to be unfounded.

Based on interviews, and record reviews, the department has determined that the allegation was false, could not have happened and/or is without a reasonable basis, therefore the allegation is UNFOUNDED.

Report was discussed with caregiver and the administrator who was on the phone.

A copy of the report was provided.

SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Murial Han
LICENSING EVALUATOR SIGNATURE:	DATE: 01/15/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/15/2026

LIC9099 (FAS) - (06/04)

Page: 7 of 7