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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005646
Report Date: 11/07/2024
Date Signed: 11/07/2024 11:04:48 AM

Document Has Been Signed on 11/07/2024 11:04 AM - It Cannot Be Edited

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 IIFACILITY NUMBER:
306005646
ADMINISTRATOR/
DIRECTOR:		GARSIN-PABALE, NOIMEFACILITY TYPE:
740
ADDRESS:129 MOUNTAIN VIEW DRIVETELEPHONE:
(657) 210-4454
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: DATE:
11/07/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Remy JardinTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Kimberly Lyman made an unannounced visit to the facility for the purpose of a Plan of Correction (POC) visit, based upon the deficiencies cited in LIC form 809D on 10/15/2024. LPA was greeted and granted entry into the facility by staff and explained the reason for the visit.

*Deficiency cited under Title 22 Regulation 87412(c) pertaining to Staff Training has been cleared. Licensee provided proof of correction. Licensee has complied with the terms of the POC.

*Deficiency cited under Health and Safety Code 1569.695(c) pertaining to Emergency Drills has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.

*Deficiency cited under Title 22 Regulation 87608(a)(3) pertaining to postural supports has been cleared. Licensee provided proof of correction. Licensee has complied with the POC.

Licensee addressed items on advisory note issued on 10/15/2024.



Licensee has been advised to maintain all items in compliance with Title 22 regulations.

Exit interview conducted and a copy of this report was left at the facility.
Alisa OrtizTELEPHONE: (714) 703-2855
Kimberly LymanTELEPHONE: (714) 795-1497
DATE: 11/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/07/2024
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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