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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 01/24/2024
Date Signed: 01/24/2024 02:47:18 PM


Document Has Been Signed on 01/24/2024 02:47 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:
(707) 559-5782
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 5DATE:
01/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Darwin Galicia,Licensee/AdministratorTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced annual inspection of this facility and met with Licensee, Darwin Galicia. Facility has 5 residents, none with dementia or under hospice care.

Facility tour began: 01/24/2024 at 9:00am with staff Imelda & licensee/administrator Darwin Galicia, facility was found to be clean and at a comfortable temperature with all exits free from obstruction. All notices that are required to be posted have been posted and are in a highly visible areas. 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. Facility kitchen, refrigerators and freezers were clean, and food was stored properly. Hot water temperature measured between 120.3. degrees F and 121. degrees F in 2 out of 2 resident’s bathroom faucets falling out of Title 22 acceptable regulation of 105 to 120 degrees F , licensee adjusted water heater during visit. Facilities two bathrooms were equipped with non-slip floor mats for safety. There was a supply of cleaners, hygiene products and paper products available for residents. Resident’s bedrooms have lighting & appropriate furnishings.

Fire Extinguishers were found to be last charged on 01/11/2024. Smoke Detector and Carbon Monoxide Detector were tested and operational. Toxins are stored in a locked hallway closet & cabinet under sink. Facility maintains a 30-day supply of medication. Facility has no required log of disaster drills conducted which are to be conducted quarterly, in different shifts (see LIC809D).

At approximately 10:30AM, LPA reviewed 5 of 5 resident records and found 5 of 5 residents did not have current Pre-Admissions Appraisals on file and 2 of 2 residents needing Re-Appraisals, Licensee did not have on file. (see LIC 809-D)

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
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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Document Has Been Signed on 01/24/2024 02:47 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: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 4 of 4 staff records reviewed. Records did not contain evidence of completed training. This poses/posed a potential health, safety or personal rights risk to persons in care
POC Due Date: 02/09/2024
Plan of Correction
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Licensee to submit written plan, detailing how facility will conduct and keep track of completed annual staff training. Written plan to be submitted to CCL by POC date of 02/09/2024.
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of his/her individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview with Licensee facility did not have preappraisals done for 5 of 5 residents in the facility which poses a potential risk to residents in care. LPA observed that R1, R2, R3, R4 & R5 were admitted without a preappraisal, no care plans are on file.
POC Due Date: 02/09/2024
Plan of Correction
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Facility agree to submit a written plan for future compliance in how the following areas are performed; pre-appraisals . In addition, appraisal for R1, R2, R3, R4, & R5 with all signatures and Written plan to be submitted to CCL by POC date of 02/9/2024
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: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/24/2024 02:47 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: 01/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(c)
Reappraisals
(c) The licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, when there is significant change in the resident's condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Licensee's file review showing that resident's care plans for 2 out of 2 residents (R2 & R3) were not been performed and signed by the resident of their representative within last 12 months. This is a potential risk to the health and safety of residents in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee agreed to review all resident's care plans, update them accordingly and send self-certification that this process had been completed to CCL by POC due date.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview, the licensee did not conduct & document an emergency drill within the past quarter. This poses a potential health and safety risk to residents in care.
POC Due Date: 02/09/2024
Plan of Correction
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Licensee agrees to conduct and document disaster drills every 3 months on all shifts with all direct care staff and submit proof to CCL by POC 2/9/2024.
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: 01/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/24/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


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: 01/24/2024
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Physician’s reports (602’s) were current for all residents. 5 of 5 resident records contained current and signed admission agreements on file. Medication records are thorough and contained physician’s orders for each resident.

At approximately 12:15 PM, LPA reviewed 4 of 4 staff records, 4 of 4 records did not contain documentation of completed training records as required (see LIC809-D). Evidence of first aid and CPR training were current. All staff either had Covid-19 vaccination documents or exemptions on file. LPA interviewed 2 staff during this inspection.

At approximately 1:30PM, LPA reviewed the facility emergency disaster plan with Licensee. Facility is working on getting a generator to supply power during an outage. 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 if more than 3 COVID-19 + in the facility. Administrator Certificate is for Darwin Galicia # 6002465740 Exp. 6/1/2025.


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 2/9/2024

LIC 308 Designated


LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 9020 Register of Facility Resident’s
Updated facility sketch showing exit door in rm 5
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 01/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024
LIC809 (FAS) - (06/04)
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