<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804046
Report Date: 07/19/2022
Date Signed: 07/19/2022 01:28:44 PM


Document Has Been Signed on 07/19/2022 01:28 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 MARIEFACILITY TYPE:
740
ADDRESS:111 GREGORY LANETELEPHONE:
(707) 210-5310
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 1DATE:
07/19/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
11:41 AM
MET WITH:Anne Belonio, LicenseeTIME COMPLETED:
01:30 PM
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) Aracei Canela arrived unannounced to conduct a Post Licensing inspection and met with Licensee, Anne Belonio. The inspection is focused on the Infection Control procedures and practices of this facility.

Upon arrival, LPA observed posters outside notifying visitors that masks must be worn in the facility and what the facility's visitation policy is. Once inside, LPA observed a screening station near the entrance that included a visitor sign in. Licensee checked LPA temperature and LPA confirmed that facility is screening visitors and will verify non-essential visitor vaccination per Provider Information Notice (PIN) 21-40-ASC. LPA initiated a walk-through of the facility around 11:50 am and observed the following: Facility has COVID-19 posters throughout, that included hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Observed staff had masks on during this visit. Commonly touched surfaces are disinfected daily. Facility will maintain documentation of staff and resident daily temperatures.

Facility has a designated visitation area outside and is allowing for visitation in resident rooms per Community Care Licensing(CCL)guidance. Staff have completed PPE training but have not been N95 fit tested. LPA and Licensee discussed visitation and activities. Facility has at least a 30 day supply of Personal Protective Equipment (PPE) including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication.

Licensee and LPA discussed the Infection Control Plan, and understands any staff or residents with Covid will need to be reported to CCL and Local Public Health immediately. LPA discussed reporting requirements and form to be submitted within 7 days. LPA reviewed and consulted regarding resident file, centrally stored log and how to use the Medication Administration Record.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Araceli CanelaTELEPHONE: (707) 588-5041
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1