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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600311
Report Date: 10/27/2026
Date Signed: 10/27/2026 02:04:36 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/27/2026 02:04 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:EVA-MARIE RESIDENTIAL CARE HOME IIFACILITY NUMBER:
415600311
ADMINISTRATOR/
DIRECTOR:		GEONANGA, EVA & GITANO, MFACILITY TYPE:
740
ADDRESS:41 LARKSPUR AVENUETELEPHONE:
(650) 994-4368
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6CENSUS: 6DATE:
10/27/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Eva GeonangaTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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To complete annual inspection of 8/27/26, LPA Jeung reviewed client and staff records, and clients' Centrally Stored Medications Records.

Eva Geonanga is not a currently certified RCFE administrator. Updated Designation of Facility Responsibility (LIC308) to be sent to CCLD BY 11/10/26.

Deficiencies of the California Code of Regulations, Title 22 are cited on following pages.
See also Advisory Notes--3 pages.
April Cowan
Audrey Jeung
DATE: 10/27/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2026
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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Document Has Been Signed on 10/27/2026 02:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 12:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/03/2026
Section Cited
CCR
87618(b)(3)(E)

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OXYGEN ADMINISTRATION
Oxygen tanks that are not portable shall be secured in a stand or to the wall.
This requirement is not met, as 2 out of 4 oxygen tanks are not secured in a stand or to the wall. Licensee failed to ensure that O2 tanks are properly secured, which poses a potential health & safety risk.
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Oxygen tanks will be secured upright in a stand or secured to the wall.
Proof of correction to be sent to CCLD BY DUE DATE.
Type B
11/03/2026
Section Cited
CCR
87618(b)(3)(B)

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OXYGEN ADMINISTRATION
"No Smoking-Oxygen in Use" signs shall be posted in the appropriate areas.
This requirement is not met, as there are no "Oxygen in Use" signs posted for client #5, which poses a potential health and safety risk to clients in care.
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"Oxygen in Use" sign is posted on bedroom door of client #5 in LPA's presence.
Additional sign shall be posted at front entrance door and proof of correction to be sent to CCLD BY DUE DATE
Type B
11/03/2026
Section Cited
CCR87618(b)(3)(F)

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OXYGEN ADMINISTRATION
Plastic tubing from the nasal canula or mask to the oxygen source shall be long enough to allow the resident movement within his/her room but does not constitute a hazard to the resident or others. This requirement is not met, as client is attached to O2 tubing & she walked from rear bedroom down hallway
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Oxygen tubing shall be limited to use within client's room, and shall not pose a tripping hazard to roommate or any other persons.
Portable oxygen source shall be available when client is outside of her bedroom
Proof of correction shall be sent to CCLD BY DUE DATE
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to dining room/kitchen. Oxygen from a portable source shall be used by residents when they are outside of their rooms. Licensee failed to ensure that O2 tubing is confined to room of client #5, which poses a potential health, safety or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2026 02:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 01:08 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2026
Section Cited
CCR
87609(b)(4)(B)

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ALLOWABLE HEALTH CONDITIONS & USE OF HOME HEALTH AGENCIES
The written agreement shall include day & evening contact information for the HH agency...method of communication between the agency & the facility, which may include verbal contact, electronic mail, or logbook.
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Visiting HH workers shall document their visits in designated log books provided by facility.
Proof of correction to be sent to CCLD BY DUE DATE.
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This requirement is not met, as 2 visiting HH workers are observed during today's visit, but staff confirmed that no written record is maintained for their visits. Licensee failed to ensure that visiting health workers document their visits for facility records, which poses a potential health or safety risk for clients.
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Type B
11/10/2026
Section Cited
CCR87507(g)(3)(A)

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ADMISSION AGREEMENT
Admission agreements shall specify,,,
Rate for all basic services which the facility is required to provide in order to obtain and maintain a license. This requirement is not met, as admission agreements for 3 out of 6 do not include
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Admission agreements for clients #4, #5, #6 will include monthly rates, and proof of correction to be sent to CCLD BY DUE DATE. Monthly rates must have written acknowledgement by clients' responsible parties.
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monthly rate. Licensee failed to ensure that admission agreements include monthly rate for basic services, which poses a potential health, safety or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/27/2026 02:04 PM - It Cannot Be Edited


Created By: Audrey Jeung On 10/27/2026 at 01:28 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 10/27/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2026
Section Cited
CCR
87463(a)

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REAPPRAISALS
The pre-admission appraisal... shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition... and to keep the appraisal accurate. This requirement is not met, as
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Updated and signed appraisals for clients #1, #2, #3, #4, #5 will be sent to CCLD BY DUE DATE.
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5 out of 6 clients have appraisals dated more than 12 months ago. Licensee failed to ensure that annual appraisals are maintained, which poses a potential health, safety or personal rights risk to clients in care.
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Type B
11/10/2026
Section Cited
CCR87468(b)(1)(A)

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PERSONAL RIGHTS
The licensee shall have each resident and the resident's representative sign a copy of these rights, and the signed copy shall be included in the resident's record. This requirement is not met, as Personal Rights forms for 4 out of 6 clients are incomplete,
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Signed and completed Personal Rights forms for clients #1, #3, #4, #6 will be sent to CCLD BY DUE DATE
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and not signed. Licensee failed to ensure that Personal Rights forms are signed by client or their responsible parties, which poses a potential health, safety or personal rights risk to clients 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.
April Cowan
NAME OF LICENSING PROGRAM MANAGER:
Audrey Jeung
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/27/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/27/2026


LIC809 (FAS) - (06/04)
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