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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600311
Report Date: 09/09/2024
Date Signed: 09/09/2024 11:24:14 AM


Document Has Been Signed on 09/09/2024 11:24 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: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:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:40 AM
MET WITH:Eva Geonanga, Administrator/LicenseeTIME COMPLETED:
11:45 AM
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On September 09, 2024, Licensing Program Analysts (LPAs) Kiran Jain and Grace Donato, and Licensing Program Manager (LPM) April Cowan arrived at the facility at 8:40 AM to conduct the Annual 1-year required inspection. LPAs and LPM met with Eva Geonanga, Licensee/Administrator, and explained the purpose of the visit.

LPAs and LPM toured the physical plant and found it to be clean at a comfortable indoor temperature with all exits free from obstruction. This is a single-story building with 3 resident bedrooms, 1 staff bedroom, 2 bathrooms, a living room, and a kitchen with dining. No accessible bodies of water or hazards were observed. The fire extinguisher was fully charged and last serviced on 11/2023. The smoke detector and carbon monoxide detector were fully operational. The attached garage was observed to be clean with a washer and dryer for laundry and extra food supply storage.

All rooms were observed to be clean with sufficient furniture and lighting. LPAs observed auditory alarms in resident bedrooms operable and are required for residents with Dementia. The bathroom was observed to be mold-free and contained grab bars, liquid soap, and paper towels. The bath area had a shower curtain and a nonskid mat. The hot water temperature in the bathroom sink faucet was measured at 105.3°F.

Sharp objects, detergents, poisons, and soap were observed to be accessible to persons in care. In the presence of the LPAs, they were locked and are no longer accessible to persons in care. No expired food items were observed. The facility had the required 7 days of non-perishables and 2 days of perishables.

LPAs reviewed five resident records and three staff records. All were observed to be complete. Emergency drills are conducted quarterly with the last drill documented on 09/2024.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2024
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 2


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: EVA-MARIE RESIDENTIAL CARE HOME II
FACILITY NUMBER: 415600311
VISIT DATE: 09/09/2024
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The resident’s medications are securely stored in a locked cabinet. Centrally Stored Medication administration records were reviewed, and no expired medications were observed. The First Aid kit was checked and observed to be sufficiently stocked.

The following updated forms are requested to be submitted to CCLD:


· LIC 500: Personnel Report
· Liability Insurance
· Updated Administrator Certificate

No deficiencies were cited during today's visit.

An exit interview was conducted. This report was reviewed with Eva Geonanga, Licensee/Administrator, and a copy of this report was left at the facility.
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Kiran JainTELEPHONE: 650-416-4836
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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