496804020-1-12-2023-21-AS-SHAN-CMZUDD-20230112142921

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 01/12/2023
Date Signed: 01/12/2023 02:29:32 PM

Document Has Been Signed on 01/12/2023 02:29 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 RCFE		FACILITY NUMBER:	496804020
ADMINISTRATOR:	GALICIA, DARWIN		FACILITY TYPE:	740
ADDRESS:	1004 S MCDOWELL BLVD		TELEPHONE:	(707) 210-5635
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 4	DATE:	01/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Darwin Galicia - Administrator		TIME COMPLETED:	02:30 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) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection and met with Licensee, Darwin Galicia. Facility has 4 residents, 1 with dementia, and 2 residents under hospice care. During tour of facility on 01/12/2023 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. Facility has at least two days of perishable and one week of non-perishable food. During tour with Licensee at 12:15pm, sharps drawer in kitchen was observed to be unlocked and accessible to residents in care (see LIC809-D). Hot water temperature measured between 112.4 degrees F and 114.2 degrees F in 2 out of 2 resident’s bathroom faucets which are within Title 22 acceptable regulation of 105 to 120 degrees F. Facilities Two bathrooms were equipped with non-slip floors and mats for safety and stocked with hand hygiene products. There was a supply of cleaners, hygiene products and paper products available for residents. Resident’s bedrooms have lighting & appropriate furnishings. Fire Extinguisher was found to be last charged on 8/4/2021, not within fire clearance regulations (see LIC809-D). Smoke Detector and Carbon Monoxide Detector were tested and operational. Toxins are stored in a locked hallway closet & during today’s inspection, unlocked cabinet under sink (see LIC809-D). Medications are centrally stored and locked in a closet located in the hallway and inaccessible to residents. Facility maintains a 30-day supply of medication. Disaster Drills have been conducted quarterly with the last one being conducted on 10/2022. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: 01/12/2023

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan and Infection Control Plan. LPA observed that staff were wearing masks during this visit. Facility has more than a 30-day supply of Personal Protective Equipment (PPE). PPE supplies are located in an accessible place for all staff.

In addition, facility has a designated area for visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA Hansen reviewed Licensing Information System (LIS) with Licensee who informed all is current. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Darwin Galicia # 6002465735 Exp. 06/01/2023
Facility has a 100% COVID vaccination rate of staff.

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. Appeal of Rights Given.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 1/27/2023

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 01/12/2023 02:29 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: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire dpt.. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above in 2 out of 2 fire extinguisher was not serviced since August 4, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Licensee will contact the Fire Department to have fire extinguisher serviced. Licensee agreed to submit self-certification form as a proof of Correction (POC) that fire extinguishers have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date 1/13/2022.

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Licensee did not comply with the section cited above in 1out of 1 kitchen drawer containing knives and other sharps, was witnessed by LPA/Licensee to be unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that all sharp objects and toxins are stored in a locked storage inaccessible to residents at all times. Licensee to provide training of regulation for caregivers (with signed /dated proof) and submit to CCL by EOB 1/13/2023.

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 01/12/2023 02:29 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: 01/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87309(a)

: 87309(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observation, the licensee did not comply with the section cited above in 1 out of 1 kitchen sink cabinet containg toxins was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/13/2023
	Plan of Correction
1 2 3 4	Licensee agrees to conduct an immediate staff training to ensure dangerous items are stored inaccessible at all times. Licensee also agrees to submit staff training and signature sheet to CCL by POC 1/13/2023.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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