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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804020
Report Date: 02/06/2025
Date Signed: 02/06/2025 03:15:51 PM

Document Has Been Signed on 02/06/2025 03:15 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:GENESIS RCFEFACILITY NUMBER:
496804020
ADMINISTRATOR/
DIRECTOR:		GALICIA, DARWINFACILITY TYPE:
740
ADDRESS:1004 S MCDOWELL BLVDTELEPHONE:
(707) 559-5782
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 6CENSUS: 4DATE:
02/06/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Darwin Galicia, AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:40 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a required Annual inspection and was greeted by Caregiver. Administrator Darwin Galicia arrived later. Facility has 4 residents with 1 with dementia diagnosis. Facility has fire clearance for 6 Non Ambulatory and cleared for a Hospice Waiver for 3, although no residents currently are on hospice.

At approximately 11 am LPA and staff toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled. LPA observed locked kitchen cabinet containing cleaning supplies and sharp knives.

All bedrooms were equipped with lighting/lamp, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required slip resistant mats and grab bars. Water temperature in sink(s) accessible to residents in care measured at 107.6 to 107.7 degrees F, within the allowable range of 105 to 120 degrees F.

Fire extinguishers were observed to be charged 19/2025. Smoke/Carbon Monoxide detectors located throughout the facility were tested and operational. Exit doors have an auditory alert system that was functional at time of inspection. Facility’s last quarterly disaster drill was conducted on 01/03/2025.

At approximately 12 PM, LPA reviewed 4 of 4 resident records and found 4 of 4 residents had current Physician Assessmentss on file although 2 of 4 residents did not have current Pre-Admissions Appraisals on file, (see LIC 809-D)

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/06/2025
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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Document Has Been Signed on 02/06/2025 03:15 PM - It Cannot Be Edited


Created By: Shannan Hansen On 02/06/2025 at 01:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure. A report shall be made of each screening, signed by the examining physician. The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents. A signed statement shall be obtained from each volunteer affirming that he/she is in good health.Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on review of records, Staff #4 & #5 lack a health screening report, and #4 lacks TB test and results. the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee to ensure that staff #4 and #5 obtain a health screening, for #4 including a TB test, and results, by 2/17/25. Submit copies of the documents by POC due 10/24/23

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/06/2025 03:15 PM - It Cannot Be Edited


Created By: Shannan Hansen On 02/06/2025 at 01:48 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/06/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87457(c)
Pre-Admission Appraisal
(c) Prior to admission a determination of the prospective resident's suitability for admission shall be completed and shall include an appraisal of their individual service needs in comparison with the admission criteria specified in Section 87455, Acceptance and Retention Limitations.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on file review and interview with Licensee facility did not have pre-Admission appraisals for 2 of 4 residents in the facility which poses a potential risk to residents in care. LPA observed that R1, R2 were admitted without a preappraisal, no care plans are on file.
POC Due Date: 02/17/2025
Plan of Correction
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Licensee agrees to submit a written plan for future compliance in how the following areas are performed; pre-appraisals . In addition, appraisal for R1, R2, with Written plan to be submitted to CCL by POC date of 02/17/2025 to clear POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 02/06/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/06/2025


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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: GENESIS RCFE
FACILITY NUMBER: 496804020
VISIT DATE: 02/06/2025
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Continued from 809...

At approximately 1:00 PM on 2/5/2025 LPA conducted a review of five out of five staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1st Aid certification for staff that files were reviewed. Review of staff records revealed staff #4 & #5 do not have required health screening reports and #4 also does not have TB test results (see LIC809-D).

Medication is centrally stored in a locked closet in the hallway.

Darwin Galicia Administrator Certificate 6002465740 expires 6/1/2025. All fees are current. LPA and Admin discussed facility's Infection Control Plan and Emergency Disaster plan.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.

LPA Hansen has requested the following documents updated and submitted to CCL by 2/21/2025.
LIC500- Personnel Report
LIC308- Designation of Responsibility (if changes)
LIC9020 Register of Facility Residents
Emergency Disaster Plan (if changed)
Copy of Current Liability Insurance (when available)
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 02/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025
LIC809 (FAS) - (06/04)
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