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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601163
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:00:36 AM

Document Has Been Signed on 03/19/2024 11:00 AM - 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:UY, NANCYFACILITY TYPE:
740
ADDRESS:768 LUNDY WAYTELEPHONE:
(650) 557-1227
CITY:PACIFICASTATE: CAZIP CODE:
94044
CAPACITY: 6CENSUS: 6DATE:
03/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Jacquelyn Melosantos TIME COMPLETED:
11:00 AM
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On March 19, 2024 at 8:30 AM, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the Pre-Licensing visit. LPA Calandra was greeted by Liwayway Castro and explained the purpose of his visit. Administrator Nancy Uy, is out of the country and thus could not join the visit. Ms.Uy's daughter, Jacquelyn Melosantos joined later.

LPA Calandra conducted a physical plant tour. The facility consists of 5 bedrooms, 2 bathrooms, a garage, staff bedrooms, laundry room, living room and kitchen. Water temperature was measured at 130 degrees Fahrenheit. Jacquelyn turned down the water temperature in the presence of the LPA. All bedrooms were observed to have sufficient lighting and the required furniture. All bathrooms were observed to have the required grab bars and anti-skid mats. The facility had linens on hand for clients that were observed to be in good condition. The facility has the required 7 days of non-perishables and 2 days of perishables on hand. The front yard, backyard, and hallways were observed to be free from obstructions. The fire extinguisher was observed to be fully charged and last checked on 7/7/2023.

A component III was performed with the applicant.

LPA Calandra asked the applicant to address the following:

-Ensure water temperature is lowered to between 105 and 120 degrees Fahrenheit
-Remove hoist and other items on side of house
-Remove nails from the backyard deck
-Remove Aquarium in front of house
-Ensure that all screens are in good repair
-Ensure each bedroom has a chair and sufficient lighting
-Ensure Carbon Monoxide detector is functioning

LPA will return to conduct a follow-up visit to ensure the above items have been addressed.

The report was reviewed with Jacquelyn Melosantos. A copy of the report was left at the facility.
SUPERVISORS NAME: Cara Smith
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/19/2024
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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