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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600178
Report Date: 11/18/2023
Date Signed: 11/18/2023 02:03:16 PM

Document Has Been Signed on 11/18/2023 02:03 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:EUCALYPTUS HOUSEFACILITY NUMBER:
415600178
ADMINISTRATOR:ANTHONY GRACIAFACILITY TYPE:
772
ADDRESS:2 EDGEWOOD COURTTELEPHONE:
(650) 994-7110
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 12CENSUS: 8DATE:
11/18/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Angel CarterTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct an annual required visit. LPA met with facility staff C. Malbas and explained the purpose of the visit. Staff contacted management staff via cell. Program Director (PD) Angel Carter and Director of Residential Services (DRS) Carolyn Rapier requested LPA Valerio conduct the rest of the visit PD and DRS.

The facility is a two story residential home licensed to provide services to adults 18 years of age and older, all of which need to be ambulatory. LPA observed 1 staff on shift and 7 residents in the home. 1 resident was out on an outing during the visit. LPA Valerio and Facility Staff Malbas toured the facility to ensure compliance with Title 22 regulations. LPA observed both floors of the facility. Resident bedrooms were furnished, clean, and free from debris. Resident bathrooms were fully stocked with paper towels, a trash can, and hand soap. Common areas were fully furnished. Technical Assistance was provided for a couch located on the second floor of the common living area. The couch had one area on the seat that was pealing and torn, which needs to be replaced. The facility was observed to have an emergency supply of food, emergency supplies, and multiple first aid kits. Sharps, toxins, and cleaning supplies were locked away and inaccessible to residents in care. LPA observed fire extinguishers, a fire pull alarm system, and carbon monoxide detectors to be in working condition. The facility's last emergency drill was conduct on October 18, 2023. LPA observed staff assisting residents with medications, questions, and administrative task. Residents were observed cleaning their room, practicing yoga, listening to music, and completing their ADLs.

LPA was met by PD and DRS to carry out the rest of the annual inspection. LPA was provided facility files. LPA reviewed 3 staff files and 4 resident files. Staff files were observed to be complete with up to date training and background clearance. Resident files were observed to be up to date with necessary files. Administrator Anthony Garcia no longer works for the organization. DRS Rapier stated that the facility communicated with the Regional Office regarding the administrator change.
Continues on LIC 809 - C...
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2023
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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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: EUCALYPTUS HOUSE
FACILITY NUMBER: 415600178
VISIT DATE: 11/18/2023
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...Continued from LIC 809

Regional Office (RO) File Review shows the RO has the copy of the current Administrator, Carolyn Rapier, Certificate # 6061161735 and an updated LIC 500.

LPA requested the following documentation be sent to the Regional Office:
    LIC 308 - Designation of Facility Responsibility
    LIC 610E - Emergency Disaster Plan
    LIC 309 - Administrative Organization
    Proof of Control of Property

Per California Code of Regulations (CCR) - Title 22 - no deficiencies were observed today. An exit interview was held, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2023
LIC809 (FAS) - (06/04)
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