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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402896
Report Date: 11/01/2021
Date Signed: 11/01/2021 02:37:52 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GENESIS MANORFACILITY NUMBER:
366402896
ADMINISTRATOR:GERRY MARKIEFACILITY TYPE:
740
ADDRESS:6354 SACRAMENTO AVETELEPHONE:
(909) 262-9802
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 6DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Gerry Markie Alaina HendrickTIME COMPLETED:
02:00 PM
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On 11/1/21 Licensing Program Analyst (LPA) Shaunte Henry arrived at the facility to conduct an unannounced annual inspection with an emphasis on infection control. LPA met with Licensee Gerry Markie and Administrator Alaina Hendrick, explained the nature of the inspection and was granted entry into the facility. LPA’s temperature was taken with an infrared/temporal thermometer and the LPA was screened for COVID-19 symptoms. There are currently 6 residents at the facility (4 out of 6 residents are vaccinated). All 6 staff are vaccinated. As of this date there are no positive COVID-19 cases or individuals with COVID-like symptoms present in the facility.

LPA toured the facility with the administrator. There is one point of entry for routine COVID-19 symptoms screening that is initiated for all residents, staff and visitors. Signs have been posted throughout the facility, which indicates the visitor policy and proper hand washing, cough/sneeze etiquette, and social distancing practices. Facility also documents daily temperature and COVID-19 symptom checks, and any change in condition for staff and residents. All residents have at least a 30-day supply of medications. LPA observed that all emergency contact information for the residents have been updated. LPAs observed a sufficient supply of hand hygiene, cleaning and disinfecting items. LPA observed a sufficient supply of Personal Protective Equipment (PPE) that included surgical masks, N-95 masks, face shields, gloves, gowns, etc. The facility has a designated infection control person who is responsible for ensuring that the facility is compliance with infection control practices. The facility has a COVID mitigation plan in place, which outlines testing requirements, isolating/quarantining positive COVID-19 cases, proper cleaning/sanitizing/disinfecting and monitoring of individuals for COVID-like symptoms. The facility is aware that it is mandatory that Community Care Licensing (CCL) is contacted if anyone tests positive for COVID-19.

According to California Code of Regulations, Title 22, Division 6, there were no deficiencies observed or cited during this visit. An exit interview was conducted where this report was discussed with and provided to the Alaina Hendrix.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Shaunte HenryTELEPHONE: (951) 217-0236
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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