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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197803648
Report Date: 06/04/2021
Date Signed: 06/10/2021 05:04:24 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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 IIFACILITY NUMBER:
197803648
ADMINISTRATOR:GERRY MARKIEFACILITY TYPE:
740
ADDRESS:2123 AQUINAS AVE.TELEPHONE:
(909) 262-9802
CITY:CLAREMONTSTATE: CAZIP CODE:
91711
CAPACITY:6CENSUS: 6DATE:
06/04/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:29 AM
MET WITH:Alaina HendrickTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Linda Almaraz conducted an annual required visit at the facility above. LPA met with Licensee Gerry Markie and Administrator Alaina Hendrick and explained the reason for the visit. LPA used the infection control tool to evaluate the facility. LPA observed the facility plant, COVID-19 procedures, reviewed residents' medications and observed food supply. Facility has submitted a mitigation plan and is pending approval.

The facility is a 3 bedroom, 2 bathroom home located in a residential neighborhood. Facility has a main entry point for screening. All 3 residents bedrooms were toured. Each bedroom had required furniture and equipment. All bathrooms were toured and the toilets, hand washing and shower are safe and sanitary. Bathrooms had paper towels and hand soap. The food in the kitchen was sufficient supply of 2 days perishable and 7 days non-perishable. The common areas such as living room and dining area are clean and have the required furniture. The backyard has a shaded area and sitting area. Medications are centrally stored, locked along with the records. Carbon monoxide and smoke alarm detectors were tested and working. Water temperature in both bathrooms were within required range of 105-120 degree F.


An exit Interview was conducted with the Administrator and a hardcopy was provided.
SUPERVISOR'S NAME: Christine YeeTELEPHONE: (323) 981-3978
LICENSING EVALUATOR NAME: Linda M AlmarazTELEPHONE: (323) 981-3307
LICENSING EVALUATOR SIGNATURE:

DATE: 06/04/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/04/2021
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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