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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600178
Report Date: 07/31/2025
Date Signed: 07/31/2025 10:24:20 AM

Document Has Been Signed on 07/31/2025 10:24 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:EUCALYPTUS HOUSEFACILITY NUMBER:
415600178
ADMINISTRATOR/
DIRECTOR:		CAROLYN RAPIERFACILITY TYPE:
772
ADDRESS:2 EDGEWOOD COURTTELEPHONE:
(650) 994-7110
CITY:DALY CITYSTATE: CAZIP CODE:
94014
CAPACITY: 12CENSUS: 11DATE:
07/31/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Program Director, Angel CarterTIME VISIT/
INSPECTION COMPLETED:
10:35 AM
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On July 31, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced case management visit in relation to an incident that occurred on 7/13/25. LPA met with Program Director, Angel Carter and explained the purpose of the visit.

The Licensee reported, on 7/13/25, Resident 1 (R1) knocked on staff office and reported that he/she attempted to commit suicide. Staff observed R1 with a towel wrapped around his/her neck and blood stains. Staff immediately called 911 and R1 stayed in the staff office until paramedics arrived. R1 notified paramedics that he/she cut his/her neck with a razor blade and then layed in bed until reporting incident to staff. R1 was transported to the hospital. Staff later found alcohol, sleeping pills and a pocket knife hidden in R1's room. R1 was transferred from one hospital to another for medical stabilization and then was transferred to a psych unit.

During the visit, LPA reviewed R1's file and spoke to staff. R1 is no longer a client at the program as R1's treatment team decided to move her into a different facility so R1 can receive the level of care needed. According to the Program Director, this was R1's first time attempting to commit suicide since he/she has been a client at the facility. R1's treatment team indicated he/she had a history of attempting to commit.

Based on R1's file, R1 was admitted to the facility on 4/25/25 and has a history of drug use, trauma, violence and suicide attempts. The last suicide attempt R1 had was at a previous facility in December of 2024 where he/she had two incidents within two days. According to the Program Director and documents reviewed, when R1 was admitted to the facility in April 2025, R1 saw his/her behavioral health therapist once a week, saw his/her case manager once a week, saw his/her psychiatrist once a month or as needed. The facility was continuing to monitor R1's symptoms and report it to R1's treatment team. The facility also has a counselor on site all day to talk to R1 when he/she needed to discuss feelings. Facility conducts room searches when there clients are suspicious and/or randomly, however according to the staff, R1 presented very well. Room checks are being conducted daily.

No citations are issued during the visit. Report is reviewed with Program Director and a copy is provided.
NAME OF LICENSING PROGRAM MANAGER: April Cowan
NAME OF LICENSING PROGRAM ANALYST: Komal Charitra
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/31/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/31/2025
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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