197607290-11-3-2023-28-AS-KRAZ-CX8UNK-20231103154405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607290
Report Date: 11/03/2023
Date Signed: 11/03/2023 03:44:10 PM

Document Has Been Signed on 11/03/2023 03:44 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GENESIS MANOR V		FACILITY NUMBER:	197607290
ADMINISTRATOR:	GERRY A. MARKIE		FACILITY TYPE:	740
ADDRESS:	550 BETHANY CIRCLE		TELEPHONE:	(909) 262-9802
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 5	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	David E. Markie		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/3/2023 at 12:25 pm. LPA was met by Administrator David Markie and explained the purpose of the visit. The facility is licensed to serve six (6) non-ambulatory residents over the age of 60 and provides care for elderly residents with dementia and is approved to retain four (4) residents on hospice. Currently the facility has zero (0) residents on hospice care. The facility may care for one (1) bedridden resident.

LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage.

Front Yard: Was clean and well maintained. No hazards were observed.

Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 111.5 degrees F. Kitchen appliances were observed to be clean and in working order.

Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting.

Linen Closet: Contained plenty linens, towels, and hygiene products.

Resident Rooms 1 - 5: LPA Ramirez observed all five (5) resident bedrooms to contain required furnishings, lighting, and linens.

Bathrooms: Water temperature in two (2) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked.

see 809-C for continuation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GENESIS MANOR V	FACILITY NUMBER: 197607290
	VISIT DATE: 11/03/2023

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Centrally Stored Medications: Was observed to inaccessible to five (5) out of five (5) residents in care. LPA Ramirez reviewed three (3) out of the five (5) resident medications. No deficiencies were observed.

Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed.

Emergency Drills: Last documented drills were conducted on 10/12/23 and 10/25/23.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable.

Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for David Markie with an expiration date of 04/23/2024.

Resident Files: Five (5) resident files were reviewed.

Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan.

Attached Garage: LPA Ramirez observed emergency water and food supply in this area. Access to garage was observed to be inaccessible to five (5) out of five (5) residents in care.

No deficiencies are being cited. Exit interview was conducted with Caregiver Campo and a copy of this report and appeals rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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