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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610047
Report Date: 10/27/2023
Date Signed: 10/27/2023 01:21:38 PM

Document Has Been Signed on 10/27/2023 01:21 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: 4CENSUS: 2DATE:
10/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Ramona (Mona) KeetonTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:35AM. Also present during today's visit was Tri Counties Regional Center Quality Assurance Specialist (QA) Liz Aced-Arnett. The LPA met with Administrator Ramona (Mona) Keeton. LPA explained the reason for today's visit. Entrance interview conducted.

The facility is vendored through Tri-Counties Regional Center as a level 3 home. LPA reviewed the following:

STAFF FILES: LPA reviewed three (3) staff files for, but not limited to: fingerprint background clearance, health screening, TB test, and training records. All three (3) staff files reviewed were in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted monthly, with the last drill conducted on 10/19/2023. Emergency disaster plan was observed to be complete and updated annually, however, the facility is utilizing the older form. LPA provided the updated form during the visit.

CLIENT FILES/CASH RESOURCES: LPA reviewed both client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All two (2) of two (2) client files reviewed were complete and contained all documentation required.

MEDICATION REVIEW: Beginning at 11:32AM, LPA reviewed medications for two (2) clients. All medications reviewed were documented and stored in compliance with regulation.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/27/2023
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Beginning at 11:55PM, the LPA, along with Administrator and QA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The following was observed:

Hardwired combination smoke alarms/carbon monoxide detectors were tested at 12:24PM and functioned properly. The fire extinguisher was observed to be fully charged and last serviced on 09/23/2023.

BEDROOMS: The facility consists of six (6) total bedrooms, four (4) of which are private client bedrooms and two (2) are designated for staff use. LPA observed all client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: Two (2) restrooms are designated for shared client use and one (1) is designated as a staff restroom. Client restrooms are clean and sanitary and in operating condition. Hot water was checked in the client restrooms and measured within the required range.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

COMMON SPACES: Living room, family room, and dining room furniture was observed to be in good condition. The LPA observed the required postings upon entry. The backyard patio contains a shaded area and is equipped with furniture for clients' use. Garage was observed to be locked and contained storage, and emergency water. Laundry room was observed to be locked and contained chemical storage and knives.

INTERVIEWS: During today's visit, LPA interviewed one (1) client and one (1) staff.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC809 (FAS) - (06/04)
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