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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 486804046
Report Date: 09/16/2022
Date Signed: 09/16/2022 10:27:36 AM


Document Has Been Signed on 09/16/2022 10:27 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
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) 563-5672
CITY:VALLEJOSTATE: CAZIP CODE:
94591
CAPACITY:6CENSUS: 0DATE:
09/16/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:01 AM
MET WITH:Ann Marie Belonio, AdministratorTIME COMPLETED:
10:40 AM
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On 9/16/2022, Licensing Program Analyst (LPA) D. Tobola arrived at this facility for the purpose of conducting a closure inspection pursuant to voluntary closure of this licensed Residential Care Facility for the Elderly and greeted by Licensee, Ann Marie Belonio.

LPA conducted a walkthrough of of the facility, inspected all rooms and the exterior of the building. There are currently no resident living in the home and the only resident facility had moved out on Monday 9/12/2022 to another licensed facility. During today's inspection LPA found no evidence that would suggest that any residents are residing on the premises. All clothing and personal items belonging to resident have been removed.

The Licensee initiated this facility closure and submitted a written statement to Community Care Licensing (CCL)) on September 12, 2022, requesting to close this facility.

Closure inspection of this facility has been completed. Facility surrendered the license to LPA Tobola, and all postings have been removed from the walls. LPA A. Canela will finalize paperwork and close facility effective today 9/16/2022.

No deficiencies cited during today's visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Dominic TobolaTELEPHONE: (707) 588-5081
LICENSING EVALUATOR SIGNATURE:
DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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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