306005629-12-11-2024-22-AS-ARJR-DBURV6-20241211122057

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306005629
Report Date: 12/11/2024
Date Signed: 12/11/2024 12:21:02 PM

Document Has Been Signed on 12/11/2024 12:21 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME:	GENESIS SENIOR LIVING I		FACILITY NUMBER:	306005629
ADMINISTRATOR/ DIRECTOR:	GARSIN-PABALE, NOIME		FACILITY TYPE:	740
ADDRESS:	824 S WINTHROPE STREET		TELEPHONE:	(714) 771-4173
CITY:	ORANGE	STATE: CA	ZIP CODE:	92869
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:46 AM
MET WITH:	Mizpah Payud-Caregiver, Noime Garsin-Pubale		TIME VISIT/ INSPECTION COMPLETED:	12:34 PM

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Licensing Program Analyst (LPA) Alvaro Ramirez, Jr. conducted an unannounced visit for the Required 1 Year Inspection. LPA explained the purpose of today’s visit, and was greeted and granted entry by Caregiver Mizpah Payud. Administrator (AD) Noime Garsin-Pubale arrived shortly after.

For today’s visit, LPA observed a total of five residents in care and two staff members on duty.
During today's visit AD Noime Garsin-Pubale showed proof that she has renewed her AD certificate. AD was reminded to post the new AD certificate once received.

LPA toured the interior and exterior portions of the facility with AD Garsin-Pubale. The facility is a one story structure and is licensed for six non-ambulatory residents, of which four may be on hospice and zero bedridden. There are a total of seven bedrooms, of which six are resident bedrooms and one staff bedroom. LPA toured each bedroom in the facility and observed that bedrooms were provided with furniture in good repair, clean linens, adequate storage space, and kept free of tripping hazards. Smoke and carbon monoxide detector and auditory exit alarms were tested and operational. There are a total of five restrooms, of which three are resident restrooms. Restrooms were observed to be in good repair, toilets were operational, and grab bars and non-skid floor mats were provided. Water temperature tested between 106.8 and 107.7 degrees Fahrenheit.

Facility met the minimum two-day perishable and seven-day non-perishable food supplies. Sharp items and knives were locked and inaccessible to residents in care. Fire extinguisher was charged and located by the kitchen.

During today's visit LPA observed the residents eating a ham sandwich, dumpling soup and fresh fruit for lunch.

CONTINUED ON LIC809-C...

Sheila Santos	TELEPHONE: (714) 334-2062
Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: GENESIS SENIOR LIVING I	FACILITY NUMBER: 306005629
	VISIT DATE: 12/11/2024

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LPA observed the emergency disaster and evacuation plan which is located by dining room hallway. Facility had back-up emergency food and water supply.

LPA observed that First Aid Kit had all the required components. LPA observed that medications and toxins were locked and inaccessible to residents in care.

For the exterior portion, LPA observed a shaded area, patio furniture, and the grounds were free of any hazards. There is one gate in the backyard, which both is self-closing and self-latching. No bodies of water were observed.

LPA reviewed five resident files and two staff files. LPA interviewed residents and staff present.

For today's visit no deficiencies were issued per Title 22 Division 6 of the California Code of Regulations.

LPA advised AD to use the general email address:

CCLASCPOrangeCountyRO@dss.ca.gov for any inquiries and to specify attention to the assigned LPA.

An exit interview was conducted with AD Garsin-Pubale.

A copy of this report was provided at the time of exit.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 334-2062
LICENSING EVALUATOR NAME: Alvaro Ramirez Jr.	TELEPHONE: 714-705-6007
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024

LIC809 (FAS) - (06/04)

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