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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 01/25/2023
Date Signed: 01/25/2023 10:31:18 AM


Document Has Been Signed on 01/25/2023 10:31 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 RCFEFACILITY NUMBER:
496804020
ADMINISTRATOR:GALICIA, DARWINFACILITY TYPE:
740
ADDRESS:1004 S MCDOWELL BLVDTELEPHONE:
(707) 559-5782
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 4DATE:
01/25/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Darwin Galicia - LicenseeTIME COMPLETED:
10:15 AM
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An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams. Present in the meeting were Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Shannan Hansen and Licensee/Administrator Darwin Galicia.

The purpose of the office meeting was to discuss concerns identified by Licensing Agency from annual inspection:

* Fire clearance in the event of a Bedridden resident.

* Hospice initiation - informing CCL & Fire Dept.

* Required documents for all residents - 602's

*Possible exit door in a room that is not on facility sketch


No deficiencies cited during today's office meeting
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2023
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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