197803648-3-29-2024-28-AS-KRAZ-D3TPVK-20240329113916

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197803648
Report Date: 03/29/2024
Date Signed: 03/29/2024 11:39:46 AM

Document Has Been Signed on 03/29/2024 11:39 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 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: 5	DATE:	03/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:23 AM
MET WITH:	Alaina Hendrick		TIME COMPLETED:	12:00 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 03/29/2024. LPA was met by Administrator Alaina Hendrick and explained the purpose of the visit. Back up Administrator Elyssa Markie arrived shortly after to assist with the tour. 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 three (3) residents on hospice care.

LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with three (3) resident bedrooms, one (1) staff bedroom, two (2) 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 109.9 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 - 3: LPA Ramirez observed all three (3) resident bedrooms to contain required furnishings, lighting, and linens. All bedrooms are shared.

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: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

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: 03/29/2024

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Centrally Stored Medications: Was observed to inaccessible to five (5) out of five (5) residents in care. Medications are stored in facility hallway.

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 01/04/24 and 10/08/23.

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 Alania Hendrick with an expiration date of 07/18/2024. First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification including HCBS (Home & Community Based Services) Final Rule Training were observed.

Resident Files: Five (5) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed.

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 back up Administrator Elyssa Markie 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: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC809 (FAS) - (06/04)

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