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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610047
Report Date: 11/12/2021
Date Signed: 11/12/2021 12:43:59 PM

Document Has Been Signed on 11/12/2021 12:43 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Ramona (Mona) KeetonTIME COMPLETED:
12:47 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Required 1-year annual visit to this facility. Upon arrival LPA met with Administrator Ramona (Mona) Keeton. Facility is fire cleared for two (2) Ambulatory clients. Facility is vendored by Tri-Counties Regional Center as a Level 3 home.

LPA Dulek and Administrator conducted a tour of the facility at 11:47AM and the following was observed:

Smoke and carbon monoxide (dual) detectors tested at 12:08PM and function properly. The fire extinguisher was fully charged. Emergency/Disaster record and all other required postings were observed on the wall near the entrance.

Kitchen: The kitchen is currently under construction, due to a previous water leak in the facility. However, kitchen appeared clean and the appliances and fixtures functional. Knives and sharps are locked. LPA observed a sufficient amount of two (2) day perishable food supply and seven (7) day non-perishable food supply.

Bedrooms: There are four (4) total bedrooms; 2 (two) bedrooms designated for clients' use and two (2) bedrooms for staff/family. All bedrooms were properly furnished and had appropriate bedding and linens.

Bathrooms: There are two bathrooms designated for clients' use. One is under construction, the second bathroom was clean, properly supplied and had functional fixtures.

Common Areas: These included the living room, family room, and dining areas. The common areas were clean and properly furnished. Properly labeled medications were locked in a closet in the foyer.

Surrounding Grounds: All passageways were free of obstruction. LPA noted that the side exit gate has a lock, but it was unlocked during today’s visit. Report Continued on LIC 809-C.

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.

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GENESIS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 567610047
VISIT DATE: 11/12/2021
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Licensee stated that the side gate is locked overnight for safety. LPA advised Licensee the gate cannot be locked and made a recommendation to utilize a gate lock which can be opened from the the inside even when the lock is engaged for emergency exiting. Emergency/disaster supplies are stored in the locked garage. Cleaning supplies and laundry detergents are all kept in the locked laundry room inaccessible to clients and others.

Infection Control: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all visitors to be wearing masks, however residents and staff are not consistently encouraged to wear face coverings in common areas. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. All clients have individual rooms, so if needed, client can isolate in their own individual room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.


The following recommendation was made:
-Participate in monthly Informational Calls

No deficiencies cited. 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
LIC809 (FAS) - (06/04)
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