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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610047
Report Date: 08/30/2023
Date Signed: 08/30/2023 09:31:16 AM

Document Has Been Signed on 08/30/2023 09:31 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:
08/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Ramona KeetonTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Case Management - Other visit to this facility, as the facility requested an increase in capacity. Upon arrival LPA met with Licensee/Administrator Ramona (Mona) Keeton. Entrance interview conducted.

Facility obtained permits and completed construction on the facility to add 2 additional bedrooms. The facility received fire clearance on 08/16/2023 for 4 ambulatory clients.

During today's visit, LPA along with Licensee toured the physical plant at 09:09AM. The two (2) added bedrooms were furnished appropriately with beds, dressers, nightstands, clean linens and sufficient lighting. No immediate health and safety hazards were observed.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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