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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804046
Report Date: 04/20/2022
Date Signed: 04/22/2022 04:32:13 PM


Document Has Been Signed on 04/22/2022 04:32 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:GENESIS RESIDENTIAL CARE HOMEFACILITY NUMBER:
486804046
ADMINISTRATOR:BELONIO, ANNE MARIE V.FACILITY TYPE:
740
ADDRESS:111 GREGORY LANETELEPHONE:
(707) 210-5310
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
04/20/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Ann Marie BelonioTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Araceli Canela arrived announced to conduct a Pre-Licensing Inspection and was greeted by Applicant/Administrator, Ann Marie Belonio.
This facility received Fire Department approval for a total capacity of 6 non-ambulatory resident on 9/30/2021. LPA conducted a walk-through of the facility and observed, facility is a single story house with 4 resident bedrooms, 1 staff room, 2 bathrooms, common spaces and garage. Resident rooms are furnished per regulation with a bed, lamp, dresser, and bedside table. One bedroom does not have a chair but Applicant and LPA discussed ways to reconfigure rooms to accommodate a chair. Bathroom showers have non-skid shower mats and grab bars. There was a locked area for medications and for resident and personnel files. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed and applicant understands food requirements per regulation. The laundry area is located in garage and have a lock to secure toxins and cleaning supplies. Exit doors had working alert devices installed. Water temperature are within regulation of 105 to 120 degrees. Facility backyard has multiple areas for visiting and activities. LPA went over shed requirements and safety condition. Facility has emergency lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Facility has working fire alarms, carbon monoxide and the extinguesher was charged and serviced on 9/27/2021.

The facility has a central area to screen visitors for Covid-19 with a thermometer, hand sanitizer, masks, and a sign in log and some covid posters, LPA will send additional Covid posters to applicant so they can post them in the facility.
Pre-licensing is complete and this facility has no deficiencies.
The Component III Orientation was completed with applicant during this visit.

LPA will submit the pre-licensing application report to Application Unit Analyst in Sacramento; facility requires proof of liability insurance. Application Unit Analyst will notify applicant of application status.

SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 04/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/20/2022
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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