198204544-10-10-2023-28-AS-FFIS-CY94DQ-20231205180106

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198204544
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:37:25 PM

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

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231004142500

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: 6	DATE:	10/10/2023
		UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Gerry Markie and Marya Alpert- Licensees		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
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:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Licensee's Gerry Markie and Marya Alpert and explained the purpose for the visit.

During today's 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# 1-4 (S1-S5), a telephonic interview with Home Health LVN (LVN), and attempted interviews Residents# 1-6 (R1-R6) . (2) of (6) Residents could not be interviewed during today's visit, due to being asleep. Home Health records for R3 and R4, physician's discharge orders, and Power of Attorney written notice in agreement for discharge from home health services were also obtained.
The investigation revealed the following:
(Report Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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-20231004142500

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 IV	FACILITY NUMBER: 198204544
	VISIT DATE: 10/10/2023

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
26
27
28
29
30
31
32

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 come to this facility- disrupting the care of residents who reside in this home. (5) of (5) 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 (5) resident's records, it was discovered that there were (2) residents receiving home health care during the period of June 2023- August 2023. Records for R3 and R4 have a physician's written order for discharge from home health services and a written notice from their Power of Attorney requesting the discharge from home health services, each in their respective files. Per interview with LVN, staff of this facility never denied home health entry to this facility, to provide services to residents. (4) of (6) 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. (5) of (5) staff interviewed denied the allegation and stated that LVN never worked at 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. (4) of (6) 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 appropriate certification. (5) of (5) staff interviewed denied the allegation and stated that LVN has never worked as a staff or administrator for this facility. (4) of (6) 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, Elyssa Markie is the listed Administrator for this facility with Certificate# 6056493740. She has met the qualifications for Administrator.
Based on LPA's observations, records review, and interviews held: Although the allegation may have happened or is 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 Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2