415600645-12-2-2023-14-AS-CVAO-CY5QCY-20231202110354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 415600645
Report Date: 12/02/2023
Date Signed: 12/02/2023 11:04:03 AM

Document Has Been Signed on 12/02/2023 11:04 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		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: 3	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Gitano		TIME COMPLETED:	11:20 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) Christina Valerio arrived unannounced to the facility to conduct an annual required inspection. LPA was met by facility staff, and explained the purpose of the visit. LPA observed 3 staff on shift and 3 residents in care. Licensee Eva appointed facility designated administrator Maria Gitano to carry out the visit. LPA and Facility Staff Maria toured the facility physical plant to ensure compliance with Title 22 regulations. LPA observed the common areas of the home to be clean, organized, and free from debris. Facility staff have implemented infection control practices and were observed utilizing procedures. 4 resident bedrooms were observed. All resident bedrooms were clean and had no emergency exits obstructed. Resident bathroom was observed to be fully equipped with a skid matt, hand bars, soap, paper towels, toilet paper, and a trash can. Hot water was measured within the regulatory range of 105-120*degrees F. The kitchen was observed to be clean. LPA observed the facility to have a minimum supply of food items to meet Title 22 regulations. LPA also observed an emergency supply of food and water located in the garage. Toxins, medications, sharps, and cleaning supplies were observed to be locked and inaccessible to residents in care. The exterior plant was observed. The facility has a patio located in the back of the house with sufficient space for outdoor activities or visits. LPA interviewed staff and residents during the visit. Residents were observed watching television, getting ready for the day, and exercising. Staff were observed cleaning the dinning table from breakfast, assisting residents, and doing daily house chores. LPA reviewed staff and resident files. Staff files were observed to be up to date with required training. Three (3) resident files were reviewed. 2 out of 3 resident files were observed to have out of date documentation. Continues on LIC 809 - C ...

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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 12/02/2023 11:04 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
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: 12/02/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87463(c)

Reappraisals

(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on records review, the licensee did not comply with the section cited above in 2 out of 3 resident files which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 01/12/2024
	Plan of Correction
1 2 3 4	Licensee stated all resident files, including physician's report and appraisals, will be updated to reflect current information. Licensee to sent confirmation to the Regional Office once files have been updated.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: EVA-MARIE RESIDENTIAL CARE HOME	FACILITY NUMBER: 415600645
	VISIT DATE: 12/02/2023

NARRATIVE

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...Continued from LIC 809

The last emergency disaster drill was conducted in January of 2023. Technical Advisory was conducted for quarterly drills.

LPA requested the following documentation be sent to the Regional Office:

LIC 500
LIC 308
LIC 610
Liability Insurance

Per California Code of Regulations (CCR) - Title 22, deficiencies were observed during this visit and can be found on the attached LIC 809 - D. Appeal Rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held, and a copy of the report was provided to Facility staff Maria Gitano.

SUPERVISOR'S NAME: Stephen Richardson	TELEPHONE: (916) 263-4746
LICENSING EVALUATOR NAME: Christina Valerio	TELEPHONE: 916-263-6323
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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