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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 02/10/2022
Date Signed: 02/10/2022 11:46:10 AM

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 RCFEFACILITY NUMBER:
496804020
ADMINISTRATOR:GALICIA, DARWINFACILITY TYPE:
740
ADDRESS:1004 S MCDOWELL BLVDTELEPHONE:
7072105635
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 5DATE:
02/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Darwin Galicia - Administrator/LicenseeTIME COMPLETED:
11:45 AM
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License Program Analyst (LPA) Hansen arrived at 8:30 am to conduct an unannounced pre-licensing inspection and was greeted by staff Marita Socito, Administrator was not at facility. Staff called Administrator who arrived 20 minutes later. This is a change of ownership. Fire clearance has been approved for 6 non-ambulatory residents by the County Fire Department. Approval for Hospice Waiver of 3. LPA will conduct a component III orientation with Darwin Galicia Administrator/Licensee. There is a total of 5 residents, 1 is a dementia resident, and 3 residents under Hospice care.

Facility tour/inspection began at 9:00 AM:
Facility is a one floor facility and was found to be clean and at a comfortable temperature with all exits free from obstruction. Exits were equipped with auditory devices that were working properly during the visit. Fire Extinguisher was found to be last charged on 8/04/2021 at the time of the visit. Sample test of facility smoke detectors and carbon monoxide detectors were found to be operational. Sample of hot water temperature measured 105.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 1 of 1 resident’s bathroom faucets. The facility has a special care plan of operation and programming for residents with dementia. Facility does grocery shopping on Fridays. Food stored in the kitchen refrigerator were properly stored as per regulations. Food is available for residents any time of the day. Toxins are stored in the garage and locked hallway closet. There was a supply of cleaners, hygiene products and paper products available for residents. All bathrooms designated for residents at the facility were supplied with paper towels and hand soap dispensers. Bathrooms were equipped with necessary grab bars, and non-slip floors/mats were present in the bathroom shower. A sample tour of resident’s bedrooms show they have lighting & appropriate furnishings.

Continue LIC 809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020
VISIT DATE: 02/10/2022
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Facility floor includes kitchen, living room & family room area, bathrooms, dining room, and resident's bedrooms, and bathrooms. There is outdoor space for activities with a fully enclosed swimming pool. Resident's & Personnel records, medication, first aid supplies, and toxins will be locked in the front room office. Postings noted to be current and in compliance with guidelines. First aid kit has been placed by medications. PPE is being stored in locked hallway closet & garage. Disaster Drills have been conducted often and in different shifts with the last one being conducted on 2/04/2022.

Pre-Licensing is complete, and this facility has no apparent deficiencies. Facility is ready for licensure.



Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with process.

There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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