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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804020
Report Date: 07/17/2025
Date Signed: 07/17/2025 10:44:49 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/04/2025 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20250404112532
FACILITY NAME:GENESIS RCFEFACILITY NUMBER:
496804020
ADMINISTRATOR:GALICIA, DARWINFACILITY TYPE:
740
ADDRESS:1004 S MCDOWELL BLVDTELEPHONE:
(707) 559-5782
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:6CENSUS: 4DATE:
07/17/2025
UNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marita SocitoTIME COMPLETED:
10:50 AM
ALLEGATION(S):
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Staff are not permitting resident to leave the facility
Staff are not permitting resident to have visitors
Staff are not permitting resident to receive phone calls
Staff did not assist resident with obtaining medical care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver complaint investigation findings regarding the above allegations. LPA was greeted by staff Marita Socito who contacted Licensee who was out of the area. LPA spoke with Licensee, disused purpose of visit and authorized staff to sign for today’s visit.
During investigation LPA conducted facility visit on 4/8/2025 & 4/22/2025 and made observations, conducted interviews with staff and outside individuals, and obtained and reviewed medical and legal documents to complete this investigation.
Staff are not permitting resident to leave the facility – Complainant alleges staff are not allowing resident (R1) to leave the facility. Interviews conducted and documents obtained revealed on (12/24-shopping to Ross, 2/11/25-shopping TJ Max, 3/25 walking around neighborhood, 4/1/25 -Salon-(see pics), 4/8/25 Costco grocery shopping/Hearing aid fix, 4/23/25 Costco grocery shopping/again hearing aid fix, R1 was taken to these appointments by Administrator. Interview with Long Term Care Ombudsman (LTCO) confirmed outings. Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 21-AS-20250404112532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2025
NARRATIVE
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Continued from LIC9099:
Administrator informed other family members also have taken R1 to doctors’ appointments. Facility restricted access on the directive of the residents Power of Attorney (POA). Review of power of attorney paperwork and legal documents pertaining to restraining order indicates facilities ability to comply with POA’s directive. There was no information obtained during the investigation that supported a violation had occurred. Based on records reviewed, interviews conducted, and related information obtained during the investigation the allegation “staff are not permitting resident to leave the facility” is UNSUBSTANTIATED.

Staff are not permitting resident to have visitors- Complainant alleges staff sometimes allow visits from family and friends and sometimes they don't. Interview with Administrator revealed, POA visits 1 to 2X a week & family friends will come approximately once a week. Facility restricted access on the directive of the residents Power of Attorney (POA). This would include people who are attempting to contact R1 on behalf of individuals who have/had restraining orders. Review of power of attorney paperwork and legal documents pertaining to restraining order indicates facilities ability to comply with POA’s directive. There was no information obtained during the investigation that supported a violation had occurred. Therefore, the allegation staff are not permitting resident to have visitors is UNSUBSTANTIATED.

Staff are not permitting resident to receive phone calls- Complainant alleges facility staff sometimes don't let resident (R1) receive or make phone calls. Follow up interview with complainant provided conflicting information indicating they have daily phone conversations with R1 and is not sure of specific days, times, or of which staff do not allow calls to R1. LTCO records indicate multiple calls made to and received from R1. Documents obtained of R1’s daily activity log and Interviews conducted with facility and outside professionals revealed; R1 has their own cell phone and has used facility phone. From 2/16/2025 until 4/7/2025 R1 daily logs indicate some of R1’s either made calls or received calls to be approximately 20 times, including a call made to a family member on 4/1/2025. During said call, the police arrived due to a call indicating R1 was not being allowed to use the phone. Police report indicates R1 informed they are able to use the phone whenever and there is no issue. There was no information obtained during the investigation that supported a violation occurred. Therefore, the allegation Staff are not permitting resident to receive phone calls is UNSUBSTANTIATED.

Continue on LIC9099-C2

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20250404112532
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/17/2025
NARRATIVE
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Continued from LIC9099-C

Staff did not assist resident with obtaining medical care - Complainant alleges that R1 had a doctor appointment on 4/4/25, and after calling doctor’s office to confirm appointment, stated they spoke to R1 on the phone and R1 allegedly indicated staff are refusing to let them go to appointment even though staff was to take R1 to appointment. The department’s investigation revealed on 4/8/2025 LPA conducted unannounced visit at facility and observed R1 to be in good health and hygiene, walking around facility with a walker and having conversations with other residents, staff and LPA. Interview with administrator revealed R1 did not have a doctors appointment on 4/4/25 but has taken R1 to doctors appointments along with POA. Per Police Report regarding R1, welfare checks on 4/3/2025 & 4/4/2025 alleging facility not allowing R1 to go to hospital on 4/4/2025 and all other allegations appear to be unfounded. There was no information obtained during the investigation that supported a violation occurred. Therefore, the allegation Staff did not assist resident with obtaining medical care is UNSUBSTANTIATED.

A finding that the complaint allegations are unsubstantiated means that although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3