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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306006181
Report Date: 06/28/2022
Date Signed: 06/28/2022 11:31:11 AM


Document Has Been Signed on 06/28/2022 11:31 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 ELDERLY CARE 8FACILITY NUMBER:
306006181
ADMINISTRATOR:ROBLES, JOSEFINA L.FACILITY TYPE:
740
ADDRESS:5129 E ELSINORE AVETELEPHONE:
(714) 488-0892
CITY:ORANGESTATE: CAZIP CODE:
92869
CAPACITY:6CENSUS: 6DATE:
06/28/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Josefina Robles, Licensee/AdministratorTIME COMPLETED:
11:45 AM
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On today's date, Licensing Program Analyst (LPA) Rosie Quiroz conducted an announced visit to the facility for purpose of a Pre-Licensing evaluation. LPA was greeted, COVID-19 screened upon entry to the facility and met with Licensee/ Administrator (L/AD) Josefina Robles. An initial application to operate a Residential Care For the Elderly facility (RCFE) was submitted to the Central Applications Bureau (CAB) on 04/12/22 for a total capacity of six (6) residents, (5) five Non Ambulatory residents and (1) one bedridden resident. On 5/4/2022, the Fire Clearance was granted for five (5) non-ambulatory residents and (1) one Bedridden resident in bedroom #5 only.
During today's visit LPA Quiroz observed the following:
Structure:
Facility is a one story house with five (5) private resident bedrooms, (1) one shared bedroom and one (1) caregiver bedroom, (2) two bathrooms, living room, dining area and kitchen. There is an attached one (1) car garage in the front of the house.
Heating/Cooling System:
Wall heating and air conditioning system installed in each resident bedroom, living room area and kitchen.
Bedrooms:
Each resident bedroom will accommodate any non-ambulatory resident. All resident bedrooms were adequately furnished with bed, chair, large closets, appropriate linens, adequate lighting, and an operational smoke alarm. There was one (1) caregiver bedroom for live-in staffing.
Bathrooms:
Two (2) of two (2) resident bathrooms have a working toilet, wash basin, and shower with an adequate supply of towels, paper towels and toilet paper. At 9:55 AM, LPA began testing water temperatures in two of two resident bathrooms. Water temperatures measured between 105.0 and 109.4 degrees Fahrenheit.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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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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 8
FACILITY NUMBER: 306006181
VISIT DATE: 06/28/2022
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Kitchen/Laundry:
An adequate supply of dishes, glasses, utensils, pots and pans were observed. Cleaning supplies and knives/sharp instruments were secured in a locked cabinet and drawer. There was adequate room for food storage. Refrigerator/freezer were in working condition and had sufficient storage for perishable food. LPA observed the stove to be operational. There was adequate seating for meals for all residents. Sample menu was posted near the kitchen. Laundry area with washer and dryer were located in the garage area.
Living/Family room:
There was a living area with safe and adequate seating for all residents as well as working Television.
Linens and Hygiene Supplies
An adequate supply of linens and toiletries were stored in a closet near bedroom #1 and bedroom #2.
Yards/Outside:
There is a front patio with adequate shaded seating for all residents. Fencing secured the entire backyard. There is a front yard and an operational self-latching gate on both sides of the facility which lead to the backyard. All outdoor pathways were free of obstructions. There were no bodies of water observed anywhere on the property.
Garage:
There was a washer and dryer located in the garage area. Laundry detergents and cleaning solutions were secured and inaccessible to residents. Garage was organized and free of obstructions.
Emergency Phone Numbers, and Exit Plan:
Let-Us-No poster, Ombudsman poster, and AD certificate were posted in the entry way and kitchen area. Emergency phone numbers were posted in the dining room. Facility exit plan was posted near the front door. 72 hour emergency supplies and water were observed in in pantry area next to refrigerator.
General items:
One (1) Fire extinguisher was charged and mounted in the kitchen area, last services on 1/24/2022. Twelve (12) smoke alarms and twelve (12) carbon monoxide detectors were tested and found to be in working order. Emergency lighting was located throughout the facility. Resident records and staff files were stored in locked and secured filing cabinet in kitchen area. A complete First Aid kit and locked area for medication storage was observed. LPA observed a facility phone and it was verified to be operational utilizing LPA Quiroz's cellphone.

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SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
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 8
FACILITY NUMBER: 306006181
VISIT DATE: 06/28/2022
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Emergency Items:
Emergency disaster including water, food, flash lights, blankets, batteries, extra incontinent supplies, and PPE readily available in an event of an emergency in the hallway area next to bedroom #5.
Fire Clearance: Approved on 5/12/2022 for a capacity of 6 Non Ambulatory residents. LIC 610 E form observed posted by facility entrance readily available for staff and residents in an event of an emergency. LIC 808 Mitigation Plan dated 01/25/2022 was reviewed and approved on today's date. A copy of LIC 808 was observed and kept in facility's emergency binder.
Appliances: Appliances were observed operational and in good repair.
Component III: Component III was completed today with Licensee/Administrator Josefina Robles.
Licensee/ Administrator Josefina Robles was reminded of the statute that requires facility to notify Rosie Quiroz, Licensing Program Analyst at (559) 753-4610 within 5 business days of admitting the first new resident. This notification may be done by phone, mail, email or fax. LPA Rosie Quiroz provided Applicant with business card to facilitate communication with LPA Quiroz.
Therefore, the facility physical plant meets requirements of Title 22 Regulations.
The pre-licensing inspection has been completed. License will be granted upon completion of a final review of the application and approval by the Central Applications Bureau.

An exit interview was conducted with Licensee/Administrator Josefina Robles, and a copy of this report was provided at exit.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Rosie QuirozTELEPHONE: (559) 753-4610
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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