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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600311
Report Date: 09/30/2021
Date Signed: 10/19/2021 08:51:37 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:EVA-MARIE RESIDENTIAL CARE HOME IIFACILITY NUMBER:
415600311
ADMINISTRATOR:GEONANGA, EVA & GITANO, MFACILITY TYPE:
740
ADDRESS:41 LARKSPUR AVENUETELEPHONE:
(650) 994-4368
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY:6CENSUS: 5DATE:
09/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Administrator, Eva GeonangaTIME COMPLETED:
12:00 PM
NARRATIVE
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On 9/30/2021, Licensing Program Analyst(LPA) Murial Han and LPA Komal Charitra conducted an unannounced annual inspection. LPAs observed COVID-19 signs posted by the entrance. LPAs were greeted by the Administrator, Eva Geonanga. LPAs explained the purpose of the visit. LPAs were screened at the front entrance, however, the Administrator was not able to provide the daily visitor screening log documentation.

LPA toured facility and grounds. No accessible bodies of water or fire safety hazards observed. Infection control practices are reviewed: entry procedures, staff training and policies, containment strategies, PPE supply and the environmental cleaning supply are adequate bathrooms are equipped with soap and paper towels, COVID-19 signs were observed to be posted through-out the facility, the beds in the semi-private rooms are either 6 feet apart or 3 feet apart from head-to-toe.

Medications, toxins and sharps are stored appropriately and inaccessible to resident, and a comfortable temperature is maintained, lighting is sufficient for comfort. There were 2 residents sitting in the dinning room maintaining social distancing. There were 5 residents and 3 staff during the annual inspection

The facility was not able to provide any documentation for the daily COVID-19 screening for the residents and staff members.

LPAs requested for an updated LIC610E by 10/4/2021.

Deficiency of the Residential Care Elderly California Code of Regulations, Title 22, Division 6 is observed and cited on a LIC 809D. Failure to correct the deficiencies may result in civil penalties.

This report is reviewed and discussed with the Administrator; a copy is provided.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EVA-MARIE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600311
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care. The facility failed to provide documentation for the daily residents and staff members screening log; the facility failed to provide documentation for the visitor's screening log.
POC Due Date: 10/14/2021
Plan of Correction
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The Administrator and/or designee will review the Department's Provider Information Notices (PINs) regarding the daily COVID-19 screening process for visitors, residents and staff members and start documenting the results of the screening outcomes on a log to indicate that it was done. The Administrator will in-service staff members on this procedure and the Administrator will provide a copy of the sign-in sheet and the required logs to the Department by 10/14/2021.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (650) 272-7906
LICENSING EVALUATOR NAME: Murial HanTELEPHONE: (619) 209-9761
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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