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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005646
Report Date: 09/08/2022
Date Signed: 09/08/2022 03:46:34 PM


Document Has Been Signed on 09/08/2022 03:46 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
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:GENESIS SENIOR LIVING IIFACILITY NUMBER:
306005646
ADMINISTRATOR:GARSIN-PABALE, NOIMEFACILITY TYPE:
740
ADDRESS:129 MOUNTAIN VIEW DRIVETELEPHONE:
(657) 210-4454
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY:6CENSUS: 6DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:57 PM
MET WITH:Remi Jardin- Caregiver TIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Andrea Mendivil conducted an unannounced visit for the purpose of conducting a required annual visit. LPA was greeted and granted entry into facility by Caregiver Remi Jardin and explained the reason for the visit. Administrator Noemi Garsin-Pabale arrived 3:10 PM

At 3:10 PM, LPA toured facility with Administrator Noemi Garsin-Pabale. Facility has 6 residents present during today’s visit. Facility is a 6 bedroom, 4 bathroom, single story home with an attached garage. LPA observed a screening and sanitizing station at entrance of the facility. LPA observed residents relaxing in the facility or in their respective rooms. Facility appears clean and sanitary. All resident rooms had required elements, including bed, chair, closet space and ample lighting. Restrooms are stocked with soap and paper towels and have hand washing postings. Facility has 2 refrigerators with ample food supply. LPA observed facility has emergency food and water supply. Facility has a secured location for resident medication and files. LPA toured the outside grounds and observed outside visitation area. Exit gates are unlocked and self latching. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation. LPA observed a 4 weeks supply of PPE. LPA reviewed all residents’ files and all contained required documentation including updated emergency information. All staff and residents are fully vaccinated for Covid 19.

No deficiencies noted during today's visit. An exit interview was conducted and a copy of this report was left at the facility.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-4084
LICENSING EVALUATOR NAME: Andrea MendivilTELEPHONE: 714-703-2738
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022
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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