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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600311
Report Date: 09/27/2022
Date Signed: 09/27/2022 11:58:17 AM


Document Has Been Signed on 09/27/2022 11:58 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
SF COASTAL AC/SC, 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:
09/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Administrator, Eva GeonangaTIME COMPLETED:
12:15 PM
NARRATIVE
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On September 27, 2022, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual infection control inspection. Upon arrival, LPA observed the COVID-19 signage posted at the front entrance. LPA met with Administrator, Eva Geonanga and explained the purpose of the visit. LPA was not screened at entry point, however observed visitor sign in sheet. Administrator was unable to provide LPA screening log documentation for staff and residents.

LPA toured the facility and grounds. No accessible bodies of water or fire safety hazards observed. This is a single story home with 3 resident bedrooms, 2 full bathrooms, and a staff room. LPA toured the kitchen and observed 2 day perishable and 7 day non-perishable. Medication cabinet was observed to be unlocked and accessible to residents in care. LPA observed kitchen to be equipped with liquid soap, paper towels, and hand-washing signs, however LPA also observed hand-towels and bar soaps. LPA advised administrator to not keep bar soaps and hand-towels in communal areas.

LPA toured full bathroom and observed it to be equipped with non-skid mat, grab bar, liquid soap, paper-towels, hand-washing sign. LPA observed trash can with no lids and bar soaps. LPA advised administrator to ensure trash cans have a fitted lid and ensure there are no bar soaps. LPA observed resident rooms and observed 2 shared rooms (bedroom #3 and bedroom #4 indicated on facility floor plan) with beds 6ft apart from each-other and 1 private room (bedroom 2). Bedroom #4 has a full bathroom; administrator removed bar soaps and hand-towels in LPAs presence. Bedroom #3 and Bedroom #4 door alarms leading outside were observed not to be working. According to file reviewed, both residents sleeping in bedroom #4 have dementia and one out of two residents in bedroom #3 has dementia. Staff room observed with two beds, 6ft apart from each-other. Extra linen was observed to be present and first aid kit was observed to be completed.

LPA toured the dining room and living room to be clear from any tripping hazards. During the visit, LPA Charitra observed 3 residents in the living room watching television and maintaining social distancing. A comfortable temperature of 72 degrees F is maintained and lighting is sufficient for comfort.

CONT. to 809C.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
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 5


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: EVA-MARIE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600311
VISIT DATE: 09/27/2022
NARRATIVE
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LPA toured the garage and observed chemicals to be locked, however LPA observed knives to be unlocked and accessible to resident. In addition, LPA observed washer and dryer to be in good working condition and observed extra food supply present. LPA observed 30-day PPE supply present.

Infection control practices are not observed: daily monitoring log for residents and visitors, and face coverings for staff.

87468.1(a)(2)- Personal Rights of Residents in All Facilities- This is the second repeat violation within 12 months. Facility was cited on 9/30/2021 under section 87468.1(a)(2).

$250.00 CIVIL PENALTY ASSESSED FOR REPEAT VIOLATION WITHIN 12 MONTHS.

LPA requests the following forms to be submitted to CCLD by 10/4/2022:
  • LIC308 Designation of Administrative Responsibility
  • LIC500 Personnel Report
  • LIC610E Emergency Disaster Plan
  • Administrator Certificate

Deficiency cited today under California Code of Regulations, Title 22, Division 6, Chapter 8 follows on LIC809D. If cited deficiency is not corrected by the due date, a civil penalty may be assessed.

This report was reviewed and discussed with Administrator, and a copy is provided. Appeals Rights were given. Civil penalty was also provided.
SUPERVISOR'S NAME: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:

DATE: 09/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 09/27/2022 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited

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87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

Violation of this regulation is not met as evidence by:
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Based on observations, LPA observed drawer with sharps to be unlocked and accesible to residents which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
09/28/2022
Section Cited

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87465 Incidental Medical and Dental Care: (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

Violation of this regulation is evidenced by:

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Based on observation, facility failed to ensure that medications were locked and stored appropriately and inaccesible to residents which poses an immediate health and safety risk to residents in care
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 5 of 5


Document Has Been Signed on 09/27/2022 11:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SF COASTAL AC/SC, 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: 09/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/28/2022
Section Cited

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87468.1 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.

Violation of this regulation is evidence by:
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Based on observations, facility staff failed to wear a face covering when providing care and supervision to residents. In addition, Administrator was unable to provide LPA screening log documentation for residents and staff.
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Civil penalty of $250.00 is assessed for repeat violation within the last 12 months.
Type A
09/28/2022
Section Cited

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87705 Care of Persons with Dementia: (j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

Violation of this regulation is evidenced by:
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Based on observations door alarms in bedroom #3 and bedroom #4 are not in good working condition. In addition, based on file reviewed, residents in bedroom #4 both have dementia and one out of two residents in bedroom #3 has dementia. This poses an immediate health and safety risk to residents in care.
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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: Jackie JinTELEPHONE: (714) 319-3786
LICENSING EVALUATOR NAME: Komal CharitraTELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:
DATE: 09/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/27/2022
LIC809 (FAS) - (06/04)
Page: 4 of 5