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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610047
Report Date: 10/31/2022
Date Signed: 10/31/2022 10:58:41 AM

Document Has Been Signed on 10/31/2022 10:58 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, 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:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ramona KeetonTIME COMPLETED:
11:05 AM
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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 Licensee/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 Licensee conducted a tour of the facility at 10:26AM and the following was observed:

Smoke and carbon monoxide (dual) detectors tested at 10:37AM and function properly. The fire extinguisher was fully charged and purchased on 10/19/2022. Emergency/Disaster record and all other required postings were observed on the wall near the entrance.

Kitchen: The 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 and water.

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. Both bathrooms were clean, properly supplied and had functional fixtures. Water temperature was measured in the downstairs bathroom and was 113.3 degrees Fahrenheit at 10:28AM, which is within the required temperature range.

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. Emergency/disaster supplies are stored in the locked laundry room. Cleaning supplies and laundry detergents are all kept in the locked laundry room inaccessible to clients and others.

Report Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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: 10/31/2022
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Surrounding Grounds: The facility is currently under construction to add 2 additional rooms above the garage. Licensee indicated all permits have been obtained for construction. The construction will not affect living spaces for the clients. At the current time demolition has begun and some loose bricks were observed, but all passageways were observed to be free of obstruction at the time of the visit.

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. 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.

No citations were issued. 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: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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