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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610047
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:09:40 PM

Document Has Been Signed on 12/18/2024 03:09 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:GENESIS ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
567610047
ADMINISTRATOR/
DIRECTOR:		KEETON, RAMONAFACILITY TYPE:
735
ADDRESS:1926 BANCROFT STTELEPHONE:
(775) 397-0114
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 4CENSUS: 4DATE:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:00 PM
MET WITH:Ramona "Mona" KeetonTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 12:00 P.M. 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. The Facility does handle cash resources for some of the clients, however at the time of the visit, no client require this service. Surety Bond is current. The following was observed:

Beginning at 12:20 P.M., the LPA, along with Administrator 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.

Hardwired combination smoke alarms/carbon monoxide detectors were tested at 2:45 P.M. and functioned properly. The fire extinguisher was observed to be fully charged and last purchased on 09/21/2024. This facility is a two story house, all six (6) bedrooms are in the second floor.

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. LPA observed a complete first aid kit under the sink.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GENESIS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 567610047
VISIT DATE: 12/18/2024
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Continued from LIC 809-C

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA conducted a review of expiration dates on product labels. At 12:23 P.M. hot water measured at 109.1 degrees Fahrenheit.

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 facility maintained a comfortable temperature of 73 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. There is also an ample supply of linen, towels and paper products. LPA observed night-lights were present in the hallways.



OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for clients’ use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted at the time of the visit. Facility has one side gate. LPA observed a side gate to be self-latching and closing with clear passageways for emergency exit use. LPA observed a locked shed, there lawn mower and gardening tools are stored.

Garage: The garage is attached to the house. Garage was observed to be locked. LPA observed a freezer and a fridge containing extra food for clients use. Emergency water was observed in the garage.

LAUNDRY ROOM: Laundry room was observed to be locked and contained chemical storage, knives and clients and staff files.

CLIENT FILES: Beginning at 12:54 P.M., LPA reviewed all four (4) client files for, but not limited to: physician's report, proof of TB test, Admission Agreement, and cash resources. All client files reviewed were complete and contained all documentation required.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: GENESIS ADULT RESIDENTIAL FACILITY
FACILITY NUMBER: 567610047
VISIT DATE: 12/18/2024
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Continued on LIC 809-C

STAFF FILES: Beginning at 1:41 P.M., 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.

MEDICATION REVIEW: Beginning at 2 P.M., LPA reviewed medications for four (4) clients. LPA observed the medication securely stored in a locked safe located in the hallway near the entrance of the home. All medications reviewed were documented and stored in compliance with regulation.

LPA requested the following documents: Personnel Record LIC 500, Register of facility Clients/Residents LIC 9020, Liability Insurance and Surety Bond. Emergency disaster drills are conducted monthly, with the last drill conducted on 11/30/2024.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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