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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 05/12/2022
Date Signed: 05/12/2022 01:23:43 PM


Document Has Been Signed on 05/12/2022 01:23 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 RCFEFACILITY NUMBER:
496804020
ADMINISTRATOR:GALICIA, DARWINFACILITY TYPE:
740
ADDRESS:1004 S MCDOWELL BLVDTELEPHONE:
7072105635
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 4DATE:
05/12/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Darwin GaliciaTIME COMPLETED:
01:23 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced post-licensing infection control inspection to this facility and was welcome by staff Marita Socito. Staff called Administrator Darwin Galicia who arrived approximately 30 minutes later. Facility has 4 residents with 2 under hospice care at this time.

S1 greeted LPA by opening the front door, S1 was observed not wearing a mask and S2 walked around the corner, into the front room also without a mask on. LPA requested S1 & S2 put masks on and discussed the mandated requirement to wear the mask in the facility. LPA observed hand sanitizer at the entrance and a log in binder for temperatures of visitors and answering questionnaire.

During tour the facility on 5/12/2022 with licensee/administrator Darwin Galicia, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Sample tour of resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 8/4/2021. Hot water temperature measured between 110.1 degrees F and 110.1 degrees F in 2 out of 2 resident’s bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. Toxins are stored in a locked hallway closet & locked cabinet under sink. There was a supply of cleaners, hygiene products and paper products available for residents. The bathrooms designated for residents at the facility were supplied with individual paper towels; hand soap dispenser was available. Sample resident’s bedrooms have lighting & appropriate furnishings.
Infection Control:
Facility has submitted a mitigation program plan that has been approved at this time. Some posters have been placed at facility entrance. Facility has PPE supply stored in locked hallway closet. Resident’s medications are centrally stored and locked in office cabinet.
Facility has a 30-day supply of medication for residents. Residents aren’t wearing masks inside the facility. Administrator stated staff have received PPE training and acquired N-95 fit testing.

Continue on LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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: 05/12/2022
NARRATIVE
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LPA was given names of staff working at the facility. LPA was informed by S2, S2 has been working at facility for 7 months. Administrator informed S2 started 11/2021 and just not associated to the new License but should be completed today. LPA confirmed with CCL it is being worked on. S2 has been working at facility more then 5 days and will be assessed a Civil Penalty.


Immediate Civil Penalties are being assessed in the amount of $500 due to staff S1 not being associated to the facility.

*****Total Civil Penalties issued today in the amount of $500.00
Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.



Department is requesting the following to be submitted to CCLD by 5/27/2022:

LIC 500
LIC 9020
Copy of liability insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4
Document Has Been Signed on 05/12/2022 01:23 PM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1(a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation of S1 and S2 not wearing a mask upon LPA arrival. This is an immediate Health and Safety risk to residents in care.
POC Due Date: 05/13/2022
Plan of Correction
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Administrator agrees to immediately conduct a staff training to ensure all staff are wearing masks and wearing them properly while in the facility. Administrator agrees to submit POC to CCL by 5/13/2022.
Type A
Section Cited
CCR
87355(e)(2)

87355(e)(2) Criminal Record Clearance...Request a transfer of a criminal record clearance as specified in Section 87355(c) This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation & record review Administrator didn't comply w/section cited above in 1 out of 4 staff weren't associated to facility which poses a potential health, safety or personal rights risk to persons in care. During visit on 5/12/2022 LPA observed staff S2 was working w/residents and not associated to facility
POC Due Date: 05/13/2022
Plan of Correction
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Admin agrees to associated S2 by POC date 05/13/2022. Admin agrees to ensure any staff working or residing in the facility are fingerprint cleared and associated.
Due to Administrators failure to associate S1 to the facility Civil Penalties are being issued today in the amount of $500.00.

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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 05/12/2022 01:23 PM - 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/12/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

87411(c)(1) PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.
Deficient Practice Statement
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This requirement is not met as evidenced by: Based on interview with Licensee, the facility did not ensure that all staff have current 1st aid. LPA learned that 4 of 4 staff do not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1, S2, S3 & S4 to CCL by POC date of 5/31/2022.
Type B
Section Cited
CCR
87507

87507 Admission Agreements: This requirement has not been met as evidence by:
Deficient Practice Statement
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Based on file review & interviews, the licensee did not comply with the section cited above in 4 out of 4, adm agreement of residents in care which poses a potential personal right risk for residents in care.
POC Due Date: 05/31/2022
Plan of Correction
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Licensee agrees to have admissions agreement updated according with Title 22 Regulations under St. Michael license facility on file for all residents.
Licensee to submit to CCL copy of all ad. agreements for residents in care by POC date of 5/31/2022.

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: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4