306003936-9-21-2021-22-AS-RQUZ-C73V6E-20210921160925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306003936
Report Date: 09/21/2021
Date Signed: 09/21/2021 04:09:31 PM

COMPREHENSIVE INSPECTION

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GENESIS ELDERLY CARE		FACILITY NUMBER:	306003936
ADMINISTRATOR:	I INCIONG/R MONTANO		FACILITY TYPE:	740
ADDRESS:	5129 ELSINORE		TELEPHONE:	(714) 771-4114
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 6	DATE:	09/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Mila Santos, Caregiver, Isabel inciong, Administrator		TIME COMPLETED:	04:22 PM

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On today’s date, Licensing Program Analyst (LPA) LPA Rosie Quiroz conducted an unannounced visit for the purpose of conducting a required annual inspection. LPA Quiroz was greeted and granted entry into the facility by caregiver Mila Santos and explained the nature of the visit. Licensees/Administrators Isabel Inciong and Ramon Montano arrived on or about 2:51pm. This facility is licensed to provide services to 6 Non-Ambulatory Residents, of which one (1) may be bedridden and has a hospice waiver for four (4) residents. Administrator (AD) AD Isabel Inciong has an Administrator Certificate with expiration date of 06/23/2022. AD Ramon Montano has an an Administrator certificate with expiration date of 2/19/2022.

On or about 2:32pm LPA Quiroz along with Caregiver Mila Santos toured the inside and outside of facility. Three staff working at facility were observed to be wearing face masks upon arrival to facility. There are six residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz interacted with residents in care. LPA Quiroz observed six of six residents in their bedrooms resting. Six of six residents appeared to be clean and well taken care of. LPA Quiroz observed required department postings in the facility as well as hand washing signs in the restrooms. All restrooms observed to have ample soap/sanitizer and appeared clean. LPA Quiroz inspected residents’ bedrooms and appeared clean and sanitary. LPA Quiroz observed a check in station in the main entry of the facility. Facility is taking temperatures daily and documenting results. LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food and water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed seating area with table and chairs for resident’s enjoyment. Facility has completed the LIC808 Mitigation plan and LPA Quiroz approved the plan dated 1/25/2021 on today’s visit.

CONTINUED ON NEXT PAGE...

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GENESIS ELDERLY CARE	FACILITY NUMBER: 306003936
	VISIT DATE: 09/21/2021

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Based on the observation made during today’s visit, the following deficiencies (listed on the LIC809-D attached) were observed and are being cited per Title 22, Division 6, of the California Code of Regulations.

This report was reviewed with Licensee/Administrator Isabel inciong, deficiencies and appeal rights were discussed with Licensee/Administrator Isabel incions, and a copy of this report, LIC 809-D, Appeal rights and LIC 9102 Technical Assistance was provided to Licensee/Administrator Inciong at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: GENESIS ELDERLY CARE	FACILITY NUMBER: 306003936
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 10/01/2021 Section Cited	1 2 3 4 5 6 7	Maintenance and Operation 87303(b)(2):(b) A comfortable temperature for residents shall be maintained at all times.(2) The facility shall cool rooms to a comfortable range, between 78 degrees F (26 degrees C) and 85 degrees F...This requirement was no met as evidenced by: At 2:45pm, LPA Quiroz
	8 9 10 11 12 13 14	recorded room temperature in living room area to be 91degrees F, Shared bedroom where R2 and R3 reside recorded at 92 degrees F, and R6's bedroom recorded at 112 degrees F. Caregiver Mila Santos stated"Oh, I will turn on AC now."This poses a potential risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021

LIC809 (FAS) - (06/04)

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