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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600645
Report Date: 02/25/2025
Date Signed: 02/25/2025 12:01:30 PM

Document Has Been Signed on 02/25/2025 12:01 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 HOMEFACILITY NUMBER:
415600645
ADMINISTRATOR/
DIRECTOR:
GEONANGA, EVA & GITANO, MFACILITY TYPE:
740
ADDRESS:9 LARKSPUR AVENUETELEPHONE:
(650) 756-8005
CITY:DALY CITYSTATE: CAZIP CODE:
94015
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/25/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Administrator, Marie Gitano TIME VISIT/
INSPECTION COMPLETED:
12:10 PM
NARRATIVE
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On February 25, 2025, Licensing Program Analyst (LPA) Komal Charitra conducted an unannounced annual visit. LPA met with Administrator, Marie Gitano and explained the purpose of the visit.

LPA toured the facility inside and outside including all of resident rooms, common areas & kitchen. The indoor and outdoor passageway was free of obstruction. No accessible bodies of water of fire safety hazards observed. This is a single story facility. There are three resident rooms; two of which are shared rooms and one single private room. Resident rooms were observed to be clean with all required furniture. Two full bathrooms were observed to be clean, odor-free and in good repair. Water temperature throughout the facility measured between 114-117 degrees F. Extra linen was observed to be present. First aid kit was observed to be complete.

Dining room was observed free from tripping hazards. A comfortable temperature of 71 degrees F is maintained and lighting is sufficient for comfort. LPA observed two day perishables and seven day non-perishables. Extra food supply was observed to be present. Medications, sharps, and chemicals were observed unlocked an accessible to residents in care.

Carbon monoxide monitors are working properly. All fire extinguishers have been checked and current as of
November 2024. LPA reviewed 4 resident records and 5 staff records. Resident records are updated, complete and signed. Staff records are complete, with training logs that have met the basic requirement. Medication review was done, and all medications are accounted for, and centrally stored medication records are updated.

Per California Code of Regulations (CCR) - Title 22, deficiencies were observed during this visit and can be found on the attached LIC 809D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties.



Report is reviewed with Administrator and copy of the report was provided to Facility staff Maria Gitano.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305
DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2025
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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Document Has Been Signed on 02/25/2025 12:01 PM - 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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066


FACILITY NAME: EVA-MARIE RESIDENTIAL CARE HOME

FACILITY NUMBER: 415600645

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 02/25/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations, LPA observed chemicals and sharps unlocked and accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care. Based on residents file reviewed, there are 3 residents with dementia, however no documentation that indicates residents are not at risk when items are accessible.
POC Due Date: 02/26/2025
Plan of Correction
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Licensee/administrator shall purchase new locks and provide LPA a copy of the reciept. In addition, administrator shall provide LPA of pictures of locked cabinets.
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.
April CowanTELEPHONE: (650) 266-8889
Komal CharitraTELEPHONE: (650) 629-4305

DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025

LIC809 (FAS) - (06/04)
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