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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204544
Report Date: 03/18/2024
Date Signed: 03/18/2024 04:48:27 PM


Document Has Been Signed on 03/18/2024 04:48 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 IVFACILITY NUMBER:
198204544
ADMINISTRATOR:GERRY A. MARKIEFACILITY TYPE:
740
ADDRESS:1691 GENESSE AVENUETELEPHONE:
(909) 596-8903
CITY:LA VERNESTATE: CAZIP CODE:
91750
CAPACITY:6CENSUS: 4DATE:
03/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Caregiver Natividad "Ida" AlmodovarTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/18/2024 at 2:40 pm. LPA was met by Caregiver Natividad "Ida" Almodovar and explained the purpose of the visit. 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. LPA Ramirez observed video surveilance in common areas. LPA requested and obtained a copy of Personnel Report (LIC 500) and Resident Roster (LIC 9020).

LPA OBSERVATIONS: Tour was given at 2:55 pm. The facility is located on residential street. The facility consists of five (5) bedrooms, two (2) bathrooms, live in staff room located in garage, kitchen, dining room, living room, linen closet, attached garage, open front yard and enclosed backyard.

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 110.1 degrees F. 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. LPA Ramirez observed Long-Term Care Ombudsman poster in this area.

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.

Attached Garage: Contained a washer and dryer. LPA observed PPE supplies. LPA Ramirez observed room in garage for live in staff. LPA Ramirez observed facility sketch which indicates this observation.

Due to time constraints, LPA Ramirez will returm to complete annual inspection. No deficiencies were observed at this time. A copy of this report was provided.

SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:
DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/18/2024
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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