496804020-9-4-2024-21-AS-BMOS-D8XTXU-20240909150744

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804020
Report Date: 09/04/2024
Date Signed: 09/04/2024 02:12:52 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/09/2024 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20240709125043

FACILITY NAME:	GENESIS RCFE		FACILITY NUMBER:	496804020
ADMINISTRATOR:	GALICIA, DARWIN		FACILITY TYPE:	740
ADDRESS:	1004 S MCDOWELL BLVD		TELEPHONE:	(707) 559-5782
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	6	CENSUS: 4	DATE:	09/04/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Darwin Galicia, Licensee/Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not issue a pre-admissions refund to responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to deliver complaint findings regarding the allegation listed above and met with Licensee/Administrator Darwin Galicia.

Staff did not issue a pre-admission refund to responsible party – Complainant alleges Licensee requested and obtained a “move-in-deposit” for perspective individual (I1) to move in to facility, although when I1 suddenly took a turn for the worse and was in the process of dying, facility was informed I1 would not be moving in and sent 3 requests for return of refund that was never responded to by Licensee. The investigation revealed: the department obtained a copy of the document indicating a deposit in the amount of $1,000. was received on 5/14/2024, indicating expected move in date was 5/23/2024. Interviews conducted revealed responsible party notified on 5/21/2024 that I1 would not be moving to the facility due to actively passing. I1 passed away 5/23/2024 and responsible party requested two times in June via email to facilities’ online website & via mail to facility approximately 7/1/2024 to return deposit.
Continue on LIC9099-C

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240709125043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/04/2024

NARRATIVE

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Continued from LIC9099

Licensee was unable to provide a pre-admission appraisal for I1 or an admission agreement. The deposit document obtained is not part of the admission agreement on file with Community Care Licensing (CCL). Deposit received in definition per Health and Safety Code “preadmission fee” means an application fee, processing fee, admission fee, entrance fee, community fee, or other fee, however designated, that is requested or accepted by a licensee of a residential care facility for the elderly prior to admission. Allegation alleged of “Staff did not issue a pre-admission refund to responsible party” is SUBSTANTIATED based on Health & Safety Code 1569.651 (g) If the applicant decides not to enter the facility prior to the facility’s completion of a preadmission appraisal or if the facility fails to provide full written disclosure of the preadmission fee charges and refund conditions, the applicant or the applicant’s representative shall be entitled to a refund of 100 percent of the preadmission fee. Licensee informed on 7/19/2024 that refund was sent to responsible party on 7/19/2024 in the full amount.

The following deficiencies were observed (see LIC 9099D) 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240709125043

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/04/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/06/2024 Section Cited HSC 1569.651(g)	1 2 3 4 5 6 7	(g) If the applicant decides not to enter the facility prior to the facility’s completion of a preadmission appraisal or if the facility fails to provide full written disclosure of the preadmission fee charges and refund conditions, the applicant or the applicant’s representative shall be entitled to a refund of 100 percent of the preadmission fee.	1 2 3 4 5 6 7	Licensee agrees to comply with regulation cited and refund due and provide a full copy of the admission agreement including preadmission fee/deposit for departments review.
	8 9 10 11 12 13 14	This requirement has not been met as evicenced by ***Based on interviews with licensee & outside party and documents obtained, Licensee did not comply with Health & Safety Code regulations provided. This is a potential risk to the health and safety of residents in care.	8 9 10 11 12 13 14	Facility has refunded monies.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC9099 (FAS) - (06/04)

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