366402896-11-25-2024-56-AS-LFAW-DBD37Y-20241125170044

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366402896
Report Date: 11/25/2024
Date Signed: 11/25/2024 05:00:59 PM

Document Has Been Signed on 11/25/2024 05:00 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GENESIS MANOR		FACILITY NUMBER:	366402896
ADMINISTRATOR/ DIRECTOR:	GERRY MARKIE		FACILITY TYPE:	740
ADDRESS:	6354 SACRAMENTO AVE		TELEPHONE:	(909) 262-9802
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	11/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:15 PM
MET WITH:	Marya Alpert, Administrator		TIME VISIT/ INSPECTION COMPLETED:	05:05 PM

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Licensing Program Analyst (LPA) LaVette Farlow made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Facility Caregiver Gerardo Alfonso and was granted entry to the facility. At the time of the visit there was two (2) staff present, and five (5) residents present. The facility is a six (6) bedroom, four (4), bathroom home, with a kitchen/dining area, living room, and attached garage. The facility is a Residential Care Facility for Elderly (RCFE) Licensed capacity is (6) current census (5). LPA was accompanied by Facility Caregiver, to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature 77 degrees Fahrenheit. LPA inspected resident’s bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, and sufficient lighting; bathrooms were clean, and appliances were operating appropriately. LPA observed sufficient furniture and lighting throughout the facility. LPA measured and observed the water temperatures in the bathrooms/kitchen to be 116.2, 115.2, and 116.2, degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area. LPA observed the Administrator did not complete an annual review of the Emergency and Disaster Plan as required. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept inaccessible to residents in care. There was a designated storage space for resident/staff files. Medications are kept inside medication closet inaccessible to residents in care. Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Food Service: Non-perishable and perishable food supply is sufficient for number of residents in care.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. All staff members working in the facility have criminal record clearance through the department.

Nedra Brown	TELEPHONE: (951) 202-5776
Lavette Farlow	TELEPHONE: 951-248-0304
	DATE: 11/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR	FACILITY NUMBER: 366402896
	VISIT DATE: 11/25/2024

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Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA observed staff file were not maintain with training or current CPR records. Technical violation issued. Medications were audited at random. LPA observed two (2) out of two (2) residents medication log was not maintain according to the prescribing physician orders. LPA observed medication listed that were not available according to the physician orders. Technical violation issued.

Based on the observations made during today’s visit, three (3) technical violation were issued, and no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809), (LIC809C) and (9102TV) was discussed and provided to Facility Administrator Marya Alpert.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Lavette Farlow	TELEPHONE: 951-248-0304
LICENSING EVALUATOR SIGNATURE:	DATE: 11/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/25/2024

LIC809 (FAS) - (06/04)

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