306005629-11-23-2021-22-AS-RQUZ-C92VPM-20211123153659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005629
Report Date: 11/23/2021
Date Signed: 11/23/2021 03:37:05 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 SENIOR LIVING I		FACILITY NUMBER:	306005629
ADMINISTRATOR:	GARSIN-PABALE, NOIME		FACILITY TYPE:	740
ADDRESS:	824 S WINTHROPE STREET		TELEPHONE:	(714) 771-4173
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY:	6	CENSUS: 6	DATE:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Noime, Garsin-Pabale,Licensee/Administrator		TIME COMPLETED:	03:51 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 and met with Administrator (AD) Noemi Garsin-Pabale and explained the nature of the visit.

This facility is licensed to provide services to residents age range 60 and over. Approved for (6) six residents, of which (6)six may be Non Ambulatory. Approved Hospice waiver for (4) four residents. Bedroom #1, 2, 3, 6, 7 are authorized for Non Ambulatory residents only. AD Noemi Garsin-Pabale has an Administrator Certificate with expiration date of 7/15/2022.

On or about 2:59pm, LPA Quiroz along with AD Noemi Garsin-Pabale toured the inside and outside of facility. There are six (6)residents in care and there are no active COVID-19 cases. During today's inspection visit, LPA Quiroz observed six (6) residents in their bedrooms resting. Six of six residents present in the facility 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. All bedrooms observed to have all required components. LPA Quiroz observed a check in station in the main entry of the facility. AD Noemi Garsin-Pabale indicated facility is taking temperatures daily; and documenting results.

LPA Quiroz observed the emergency disaster and evacuation plan. Facility has back-up emergency food, water supply as well as PPE supplies. LPA Quiroz toured the outside of the facility and observed ample seating area with tables and chairs and gazebo area for resident’s enjoyment in backyard area.

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SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2021

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 SENIOR LIVING I	FACILITY NUMBER: 306005629
	VISIT DATE: 11/23/2021

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Facility has completed the LIC 808 Mitigation plan dated 7/14/2021. The LIC 808 Mitigation Plan was approved by LPA Quiroz during today's visit.

During today's inspection visit, AD Garsin-Pabale indicated "All staff are fully vaccinated for COVID-19 and working on coordinating booster shots." LPA Quiroz reviewed 6 of 6 resident's records during today's visit.

Based on the observation made during today’s visit, no deficiencies were noted today per Title 22 Division 6 of the California Code of Regulations.

This report was reviewed with AD Garsin-Pabale, and a copy of this report and LIC 811 were provided at exit.

SUPERVISOR'S NAME: Alisa Ortiz	TELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie Quiroz	TELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

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