415600645-2-20-2020-14-AS-SKEG-BLYPGJ-20200220101825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600645
Report Date: 02/20/2020
Date Signed: 02/20/2020 10:18:34 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		FACILITY NUMBER:	415600645
ADMINISTRATOR:	GEONANGA, EVA & GITANO, M		FACILITY TYPE:	740
ADDRESS:	9 LARKSPUR AVENUE		TELEPHONE:	(650) 756-8005
CITY:	DALY CITY	STATE: CA	ZIP CODE:	94015
CAPACITY:	6	CENSUS: 5	DATE:	02/20/2020
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Maria Gitano		TIME COMPLETED:	10:30 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Sarena Keosavang conducted an unannounced Annual/ Random inspection and met with administrator, Maria Gitano. LPA disclosed the purpose of the visit and was granted entry to the facility. There were two staff and five residents present at the facility during the visit. LPA toured the indoor premises with the administrator. LPA observed the kitchen area. At 9:15 AM, LPA observed a knife that was not locked and was accessible to residents in care. Administrator stated that residents just had finished breakfast and that staff was cooking that’s why the knife was out. Administrator locked the knife under the sink and is now inaccessible to residents. LPA observed the freezer and refrigerator. There were adequate food supplies of nonperishable foods for a minimum of one week and fresh perishable foods for a minimum of two days. LPA toured the outdoor premises with the administrator. The outdoor passageways were free of obstruction. LPA observed there were no bodies of water. At 9:30 AM, LPA toured the residents’ bathrooms and bedrooms. Residents’ bedrooms have adequate lighting and is fully furnished. LPA measured the hot water temperature in residents’ bathroom at 120 degrees F. LPA observed grab bars in bathroom. LPA walked through the hallways with the Administrator. LPA observed the locked medication cabinet located in the hallway by the kitchen and was inaccessible to residents in care. In the medication cabinet, the first aid kit was present and completed with scissor, bandages, tweezers, and thermometer. Fire detectors and carbon monoxide were present at the facility. Continued on LIC 809-C

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8899
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

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	FACILITY NUMBER: 415600645
	VISIT DATE: 02/20/2020

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Staff records were reviewed. All staff have fingerprint clearance and first aid. Clients’ records were reviewed and was completed with documents such as Physician’s Report, Admission Agreement, Appraisal/ Needs and Services Plan. LPA review clients’ medication log to be accurate and maintained in compliance with label instructions and State and Federal Law.

No deficiencies observed today. Facility is operating in substantial compliance with Title 22 regulations.

An exit interview was conducted. A copy of this report was discussed and left with administrator, Maria Gitano, whose signature on this form confirm receipt of these documents.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8899
LICENSING EVALUATOR NAME: Sarena Keosavang	TELEPHONE: (650) 266-8800
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2020

LIC809 (FAS) - (06/04)

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