198204544-2-4-2023-28-AS-KRAZ-CNQVCP-20230204151927

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204544
Report Date: 02/04/2023
Date Signed: 02/04/2023 03:19:40 PM

Document Has Been Signed on 02/04/2023 03:19 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 IV		FACILITY NUMBER:	198204544
ADMINISTRATOR:	GERRY A. MARKIE		FACILITY TYPE:	740
ADDRESS:	1691 GENESSE AVENUE		TELEPHONE:	(909) 596-8903
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY:	6	CENSUS: 5	DATE:	02/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:			TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 02/04/2023 at 12:50 pm. LPA was met by Caregiver Natividad Almodovar and explained the purpose of the visit. At 1:10 pm Administrator Gerry Markie later arrived to lead tour. Facility is licensed to clients over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for three (3) hospice residents.There are curremtly zero (0) residents in hospice care. LPA requested and obtained a copy of Personnel Report (LIC 500), Resident Roster (LIC 9020), and copy of liability insurance.

LPA OBSERVATIONS: Tour was given at 1:17 pm. The facility is located on residential street. The facility consists of five (5) bedrooms, two (2) bathrooms, kitchen, dining room, living room, linen closet, attached garage, open front yard and enclosed backyard.

· Front Yard: Was clean and well maintained. No hazards were observed or large bodies of water.

· Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 119.8 degrees F. Signs promoting hand washing and social distancing were observed. Sharps were secured in cabinet and inaccessible to residents

· Dining Room/Living Room: Dining room area was clean, and LPA observed a table with 5 chairs. Living room area had 2 couches for seating. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area. LPA observed emergency food supply and emergency water supply located in cabinet.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2023

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 IV	FACILITY NUMBER: 198204544
	VISIT DATE: 02/04/2023

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

· Resident Rooms 1 - 5: All contained the required furnishings, linens and were observed to be clean.

· Bathrooms: Shared resident bathroom# 1 was observed to be clean and contained soap and paper towels. Water temperature in this bathroom was measured at 105.1 degrees F which is in the required 105 – 120 degrees F. Bathroom #2 located in resident bedroom # 4 water temperature was measured at 105.4 degrees F which is in the required 105 – 120 degrees F.

· Centrally Stored Medications: Is located near front door closet and was secured and inaccessible to clients. LPA reviewed 5 out of 5 client’s medications. First aid kit was observed and inspected.

· Attached Garage: Contained a washer and dryer. LPA observed PPE supplies.

Administrator certificate was observed for Gerry Markie with an expiration date: 07/18/24. Last fire drill was conducted on 12/08/2022. LPA observed carbon monoxide in hallways. Smoke detector is hard wired and tested during visit.

No deficiencies were cited during visit. Exit interview was conducted with Administrator Markie and a copy of this report was left.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2023

LIC809 (FAS) - (06/04)

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