<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600178
Report Date: 04/15/2024
Date Signed: 04/15/2024 02:42:50 PM

Document Has Been Signed on 04/15/2024 02:42 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/
DIRECTOR:		ANTHONY GRACIAFACILITY TYPE:
772
ADDRESS:2 EDGEWOOD COURTTELEPHONE:
(650) 994-7110
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 12CENSUS: 9DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Program Director - Angel CarterTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 04/15/2024, Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced required - 1 year inspection visit. LPA met with Program Director Angel Carter and explained the purpose of today's visit.

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 multiple staff on shift. LPA toured the facility inside and out with Angel Carter. LPA observed both floors of the facility. The lower floor is split level. Resident bedrooms were furnished, clean, and free from uncommon odors. Resident bathrooms were fully stocked with paper towels, a trash can, toilet paper, and hand soap. Common areas are fully furnished. Couch on the 2nd floor dining room adjacent to the kitchen is observed as still needing repair on one of the cushions. Per Angel she has contacted and requested a couch to be donated to replace but if needed soon they will purchase a couch. The facility was observed to have an emergency supply of food, emergency supplies, and multiple first aid kits posted through out the facility. Sharps, toxins, and cleaning supplies were locked away and inaccessible to clients. Kitchen knives are locked and located in staff office and is checked out by clients. 7 day and 2 day food supply is in place. 3 refrigerators are placed through out the facility for client use through out the facility. Clients cook their own food for meals. Facility does supply food and clients purchase their own as well. LPA observed fire extinguishers, a fire pull alarm system, and carbon monoxide detectors to be in working condition. Fire panel is on the ground floor and last inspected on 02/07/2024. Extinguishers are last inspected on 12/05/2023. The facility's last emergency drill was conducted on March 6, 2024.

LPA reviewed 2 staff files and 2 resident files. Staff files were observed to be complete with up to date training and background clearance. Resident files are observed to be up to date with necessary files. Administrator for the facility is designated as Carolyn Rapier and her certificate is current expiring on 10/2025..

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: April Cowan
LICENSING EVALUATOR NAME: Jaime Vado
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1