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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567610047
Report Date: 11/12/2021
Date Signed: 11/12/2021 12:42:19 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/17/2021 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20210917092903
FACILITY NAME:GENESIS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
567610047
ADMINISTRATOR:KEETON, RAMONAFACILITY TYPE:
735
ADDRESS:1926 BANCROFT STTELEPHONE:
(775) 397-0114
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:2CENSUS: 2DATE:
11/12/2021
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Ramona (Mona) KeetonTIME COMPLETED:
12:47 PM
ALLEGATION(S):
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Facility is not administering medications on time.
Staff made inappropriate request of client.
Facility is requiring client to go on outings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kelly Dulek, along with Tri Counties Regional Center (TCRC) Quality Assurance Specialist (QA) Liz Aced-Arnett conducted a subsequent complaint inspection at the facility today. The LPA arrived at 10:10AM and met with Licensee Ramona (Mona) Keeton. The LPA informed the Licensee of the reason for today's inspection. Entrance interview conducted.

During an initial complaint visit on 09/23/2021, LPA and QA conducted a facility tour, along with Licensee at 2:33PM, an interview with Licensee at 2:45PM, client interviews from 3:52PM to 4:37PM and gathered copies of documents pertinent to the investigation. During today's visit, LPA and QA toured the facility at 11:47AM, reviewed medications at 11:25AM, and interviewed the Administrator throughout the visit. The following was then concluded:

Interviews revealed that medications are given on time. Medication review revealed the client's MAR is filled
REPORT CONTINUED ON LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 29-AS-20210917092903
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GENESIS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 567610047
VISIT DATE: 11/12/2021
NARRATIVE
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out daily and contains no inconsistencies. Interview revealed that activities are planned with the clients' input, that staff do ask clients to participate in outings, however clients are not required to go on outings. If a client chooses to stay home instead of participate in an outing, a staff member will stay home and supervise the client. Interviews revealed that staff have only made appropriate requests of clients and that requests are in line with the clients' needs and individualized plans. Based on interviews and record review, although the alleged violation may have occurred, at this time there is insufficient evidence to prove the allegations, therefore the allegations that "Facility is not administering medications on time," "Staff made inappropriate request of client," and "Facility is requiring client to go on outings" are deemed UNSUBSTANTIATED at this time.

Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2