197803648-5-9-2023-28-AS-THEA-CRNR8U-20230509124830

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803648
Report Date: 05/09/2023
Date Signed: 05/09/2023 12:48:35 PM

Document Has Been Signed on 05/09/2023 12:48 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 II		FACILITY NUMBER:	197803648
ADMINISTRATOR:	GERRY MARKIE		FACILITY TYPE:	740
ADDRESS:	2123 AQUINAS AVE.		TELEPHONE:	(909) 262-9802
CITY:	CLAREMONT	STATE: CA	ZIP CODE:	91711
CAPACITY:	6	CENSUS: 6	DATE:	05/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:16 AM
MET WITH:	Gerry Markie		TIME COMPLETED:	01:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Tena Herrera conducted the required annual inspection. LPA arrived unannounced and met with Gerry Markie (Licensee) and explained the reason for the visit. The facility is licensed to serve 6 non-ambulatory residents and 2 hospice residents age 60 years and older. The facility is a single-story home located in a residential area consisting of: three (3) client bedrooms, 2 bathrooms, kitchen/dining area, living room, covered patio area, detached garage and staff bedroom with its own entrance. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents’ medications. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan. Physical Plant & Environment Safety: There are 3 client bedrooms, 2 client bathrooms, living room, kitchen, dining area. Clients’ bedrooms were checked and closet/drawer space to accommodate each client comfortably was available. The outdoor and passageways are free of obstruction. There are no security bars or weapons on the premises. Hygiene products are readily available and stored in dressers within the clients bedrooms. The hot water temperature was tested in kitchen and client bathrooms, they measured between 108.3 – 115.8 degrees F, these are within the required range of 105-120 degrees. The front yard is free of debris/hazards. All storage areas for cleaning solutions, and toxins are stored in a locked garage. The knives and sharp items are stored in a locked closet in hallway. The last Fire/Emergency Drill was conducted on 4/2023. Smoke detectors and carbon monoxide detectors are operable and in compliance. The fire extinguisher was observed in the dining area and is fully charged. (continued on 809-C)

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

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 II	FACILITY NUMBER: 197803648
	VISIT DATE: 05/09/2023

NARRATIVE

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Operational Requirements: There are currently 6 non-ambulatory residents residing at the facility.
Staffing: There appears to be sufficient staffing at all times in the facility. Administrator Alaina Hendrik certificate expires on 07/18/2024.
Personnel Records-Training: Staff has criminal record clearance. Staff has current first aid and CPR. Staff files are maintained at the facility located in a locked cabinet in the living room. Staff have current CPR/first aid training and sufficient on-going training. All residents have ongoing training on Care for Dementia Residents.
Resident Rights-Information: Residents personal rights poster is posted in the dining and is clearly visible.
Resident Records-Incident Reports: Resident files are kept in a locked closet and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Food Service: The kitchen was observed for the ability to prepare and serve food. LPA observed an appropriate food supply of two (2) days of perishables and one week (7 days) of non-perishables.
Health Related Service: Staff designated to administer medication has the proper annual training on file. Medication is centrally stored in a locked closet in the hallway and are in their original containers. During the visit today, LPA reviewed all 6 residents' medication.
Incidental Medical & Dental: All medications for clients are kept locked in a hallway closet and inaccessible to other clients.
Disaster Preparedness: The facility has an Emergency Disaster Plan posted with contact numbers and at least 2 relocation sites.
Emergency Intervention: Residents at this facility do not have restraints nor do they require the use de-escalation techniques.

LPA conducted 4 staff interviews and 1 resident interviews during todays visit.

Per California Code of Regulations, Title 22, and California Health and Safety Code, there were no deficiencies observed during the visit.

Exit interview held and a copy of the report was provided to the licensee Gerry Markie.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Tena Herrera	TELEPHONE: 323-980-4633
LICENSING EVALUATOR SIGNATURE:	DATE: 05/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/09/2023

LIC809 (FAS) - (06/04)

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