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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366402896
Report Date: 10/30/2023
Date Signed: 10/30/2023 02:29:13 PM


Document Has Been Signed on 10/30/2023 02:29 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
SAN BERNARDINO, 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:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Josephine Sandigan, CaregiverTIME COMPLETED:
02:15 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Genesis Manor Residential Care for the Elderly to obtain signatures on an Amended Report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report.

An exit interview was conducted where this report was discussed and provided to facility representative.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber ColemanTELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:
DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/30/2023
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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