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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607290
Report Date: 11/07/2022
Date Signed: 11/09/2022 09:59:16 AM


Document Has Been Signed on 11/09/2022 09:59 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:GENESIS MANOR VFACILITY NUMBER:
197607290
ADMINISTRATOR:GERRY A. MARKIEFACILITY TYPE:
740
ADDRESS:550 BETHANY CIRCLETELEPHONE:
(909) 262-9802
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 5DATE:
11/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Administrator David Markie TIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Required Annual visit. LPA met with Administrator David Markie. LPA discussed the purpose of the visit. LPA used the infection control tool to evaluate the facility. LPA observed COVID-19 procedures, reviewed residents’ medications, and records, observed food supply, and reviewed staff records.

The facility is a single-story residence located on a cul-de-sac street. The facility has an unfenced front yard, attached 3 car garage, enclosed backyard with an attached patio cover. During the tour, LPA observed a living room area, dining room area, kitchen, 5 bedrooms, and 2 full bathrooms. The facility provides care for elderly residents with dementia and is approved to retain 4 residents on hospice. Currently the facility has 0 residents on hospice. The facility currently has 4 non-ambulatory and 1 ambulatory residents.

All resident bedrooms were toured. Each bedroom contained a bed, linen, dresser, chair, light, and sufficient closet space. Resident bathrooms have the required grab bars and non-skid mat. The hot water was between 108.1 degrees which is within the required 105- 120 degrees. Cleaning supplies are inaccessible to residents. LPA observed the refrigerator to not have the sufficient required 2-day perishable and 7-day nonperishables.

Continued on 809C

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
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 4


Document Has Been Signed on 11/09/2022 09:59 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: GENESIS MANOR V
FACILITY NUMBER: 197607290

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/07/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(26)


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in the refrigerator/freezer did not contain the minimum one week of nonperishable foods and two day minimum of perishable foods, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/08/2022
Plan of Correction
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Licensee will provide photograph/ or receipts.
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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 11/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GENESIS MANOR V
FACILITY NUMBER: 197607290
VISIT DATE: 11/07/2022
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LPA reviewed 5 resident records to confirm emergency contact is updated and residents have health screenings on file. 4 staff records were reviewed to confirm health screenings, infection control training, and fingerprint clearances. LPA reviewed 5 residents’ medications. Medications are documented properly and stored in a secure area.

Per California Code of Regulations, Title 22, one deficiency was observed during the visit and documented on LIC 809D. Appeal rights explained and exit interview conducted with David Markie.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 11/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4