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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607290
Report Date: 01/16/2024
Date Signed: 01/16/2024 10:07:57 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Valeria Maldonado
COMPLAINT CONTROL NUMBER: 28-AS-20231004142512
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:
01/16/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Art Bastes- CaregiverTIME COMPLETED:
10:15 AM
ALLEGATION(S):
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9
Staff prevented home health agency staff from performing their duties.
Uncleared staff allowed to work in the facility.
Facility did not have a qualified administrator.
INVESTIGATION FINDINGS:
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5
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**Please note: This Licensing report will supersede the Licensing report dated 10/09/23, to provide additional information regarding the complaint. However, the findings will remain the same for all allegations- Unsubstantiated.**
Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility to deliver a superceded complaint report. LPA Maldonado met with staff Art Bastes and explained the purpose for the visit.
On 10/09/23, LPA Maldonado made an initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Licensee's Gerry Markie and Alaina Hendrick. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following records for Residents# 1-5 (R1-R5): Facesheet, Physician's Report, Pre-Placement Appraisal, and current Appraisal. LPA Maldonado also conducted interviews with Staff# 1-6 (S1-S6), Home Health LVN (LVN), and attempted interviews Residents# 1-4 (R1-R4). An interview with R5 could not be conducted due to R5 passing away in August 2023. Hospice Admission/Care Plan and Home Health records were also obtained for R5
The investigation revealed the following:
(Report Continued on LIC9099-C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
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 2
Control Number 28-AS-20231004142512
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GENESIS MANOR V
FACILITY NUMBER: 197607290
VISIT DATE: 01/16/2024
NARRATIVE
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Regarding allegation: Staff prevented home health agency staff from performing their duties.
It is alleged that a facility staff, who is not the administrator of the facility, informed a home health agency that they were not allowed to go to any of their licensed facilities- disrupting the care of residents who reside in this home. (6) of (6) staff interviewed denied the allegation, stating that home health has never been denied entry and there are currently no residents receiving home health care at this facility. After review of (6) resident's records, it was discovered that there was only (1) resident receiving home health care during the period between March 2023 to May 2023. On 05/04/23, the resident was transferred to Hospice Care, per Hospice Admission Records. Per interview with LVN, staff of this facility never denied home health entry to this facility, to provide services to a resident. (3) of (4) residents interviewed could not corroborate the allegation.
Regarding allegation: Uncleared staff allowed to work in the facility.
It is alleged that a home health LVN was allowed to work at the facility without appropriate criminal background clearance and association to the facility. After review of the Facility Personnel Report Summary and the Staff Roster, it was noted that all staff have appropriate criminal background clearance and are associated to the facility. (6) of (6) staff interviewed denied the allegation and stated that LVN never workedat the facility as facility staff. LVN only provided home health services to residents. Staff also stated that new employees are fingerprint cleared and associated prior to working at the facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied and LVN stated to have never been employed as facility staff by the Licensee.
Regarding allegation: Facility did not have a qualified administrator.
It is alleged that a home health agency's LVN was allowed to work as an interim administrator for this facility, without having appropriate certification. (6) of (6) staff interviewed denied the allegation and stated that LVN has never worked as a staff or administrator for this facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied. LVN stated that LVN has never been employed by the facility Licensee and has never worked as a staff/administrator for this facility. Per staff roster and Facility Personnel Report, LVN is not listed as a staff at this facility and is not associated. After review of staff records, David Markie is the listed Administrator for this facility with Certificate# 6015176740, expiration date: 4/23/2024. He has met the qualifications for Administrator.
Based on LPA's observations, records review, and interviews held: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.
Per California Code of Regulations, Title 22, no deficiencies were observed or cited.
Exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria MaldonadoTELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:

DATE: 01/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024
LIC9099 (FAS) - (06/04)
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