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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204544
Report Date: 03/22/2024
Date Signed: 03/22/2024 03:21:53 PM


Document Has Been Signed on 03/22/2024 03:21 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:
03/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Back-up Administrator Alaina HendrickTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent Annual Required Visit on 03/22/2024. LPA Ramirez conducted initial annual required visit on 03/18/2024. LPA was met by Caregiver Arturo Bastes and explained the purpose of the visit. Back-up Administrator Alaina Hendrick arrived shortly after to assist with inspection. 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 surveillance in common areas. LPA requested and obtained a copy of Personnel Report (LIC 500) and Resident Roster (LIC 9020).

Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 03/03/24 and 12/11/23. LPA Ramirez observed a First Aid kit in facility hallway.

Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: 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 Elyssa N Markie with an expiration date of 09/15/2024. First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed.

Resident Records: Four (4) 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.




No deficiencies were observed . Exit interview was conducted. 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: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 03/22/2024
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SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly RamirezTELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:

DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024
LIC809 (FAS) - (06/04)
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