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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402896
Report Date: 10/31/2022
Date Signed: 10/31/2022 03:26:03 PM


Document Has Been Signed on 10/31/2022 03:26 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, 1650 SPRUCE ST STE 200 MS29-27
, 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: 5DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Marya Alpert, Covering AdministratorTIME COMPLETED:
03:38 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Amber Coleman made an unannounced visit to the facility to conduct a required annual inspection, with an emphasis on infection control. LPA met with care staff Gerardo and Glenda Alfonso who phoned co-administrator Marya Alpert and licensee Gerry Markie, who confirmed that there are currently no cases/exposures of COVID-19 within the facility.

During the inspection, LPAs Bueno and Coleman interviewed administrator regarding the facility's infection control measures and inspected the facility for regulatory compliance. LPAs observed appropriate postings in the facility, including COVID-19 symptoms and infection control postings, which were in accordance with the Department's guidelines. LPAs observed that the facility was also equipped with sufficient hand hygiene supplies, sufficient cleaning/disinfecting provisions, and a supply of Personal Protective Equipment (PPE). The facility has a designated infection control lead person and mitigation plan in place which follows Community Care Licensing Division guidelines for COVID-19 testing, isolation, and properly caring for residents with COVID-19 positive results and/or exposures.

LPA Coleman and staff Alfonso toured the facility inside and out. LPA Coleman observed that the facility appears to be meeting operational requirements. LPA observed that all utilities and appliances were functioning and all passageways clear of obstruction. The facility was equipped with sufficient food supplies. All areas of the facility, including resident bedroom and bathrooms, appeared to have appropriate furnishings, are clean, and in good repair. LPAs observed no apparent health and safety risks at the time of visit.

Based on observations made during today’s inspection, no deficiencies were cited per Title 22, Division 6, of the California Code or Regulations. An exit interview was conducted where this report was discussed with and provided to licensee Gerry Markie
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Anna BuenoTELEPHONE: 951-204-4307
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2022
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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