366424424-10-30-2023-56-AS-NBRN-CX5R4K-20231031124140

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 366424424
Report Date: 10/30/2023
Date Signed: 10/30/2023 03:10:28 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Amber Coleman

PUBLIC

COMPLAINT CONTROL NUMBER: 56-AS-20231004142538

FACILITY NAME:	GENESIS MANOR VI		FACILITY NUMBER:	366424424
ADMINISTRATOR:	DAVID MARKIE		FACILITY TYPE:	740
ADDRESS:	6936 AMETHYST AVENUE		TELEPHONE:	(909) 262-9802
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Marrietta Tecson, Caregiver		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Staff prevented home health agency staff from performing their duties.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Genesis Manor VI Facility unannounced to deliver the findings of the complaint investigation into the allegations listed above. Caregiver, Marrietta Tecson answered the door and granted LPA entry. LPA introduced self and stated purpose of the visit. Caregiver notified Administrator, Marya Alpert of LPA visit. LPA spoke with Administrator and reported the purpose of the visit.

LPA interviewed staff, collected and reviewed pertinent documents and walked through the facility. LPA observed no concerns for health and safety of the residents during the visit.
It is alleged that staff prevented home health agency staff from performing their duties. During staff interviews, it was revealed that there is an ongoing conflict between staff, residents in care, their families and the home health agency staff. Staff and the families of residents in care have expressed that they no longer wish to utilize services with the home health agency. The ho of the residents me health agency refuses to discharge the residents from the services; which is posing an issue for any resident to sign up for alternate home health services.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 56-AS-20231004142538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR VI	FACILITY NUMBER: 366424424
	VISIT DATE: 10/30/2023

NARRATIVE

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Based on the information above, these allegations are UNSUBSTANTIATED. A finding of UNSUBSTANTIATED means although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. No deficiencies cited at this time. An exit interview was conducted where this report (LIC9099 & LIC9099C) was discussed, and a copy of this report was provided to Facility Representatives at the conclusion of the visit.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/04/2023 and conducted by Evaluator Amber Coleman

COMPLAINT CONTROL NUMBER: 56-AS-20231004142538

FACILITY NAME:	GENESIS MANOR VI		FACILITY NUMBER:	366424424
ADMINISTRATOR:	DAVID MARKIE		FACILITY TYPE:	740
ADDRESS:	6936 AMETHYST AVENUE		TELEPHONE:	(909) 262-9802
CITY:	ALTA LOMA	STATE: CA	ZIP CODE:	91701
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2023
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Marrietta Tecson, Caregiver		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Uncleared staff allowed to work in the facility.
Facility did not have a qualified Administrator.

INVESTIGATION FINDINGS:

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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Genesis Manor VI, Residential Care Facility for the Elderly unannounced to deliver findings of the complaint investigation into the above-mentioned allegations. LPA introduced self and stated purpose of the visit. Caregivers/Staff introduced themselves as Marrietta Tecson and granted LPA entry into the facility, then contacted the Administrator, Mayra Alpert to notify of LPA visit. LPA spoke with Administrator, Marya Alpert to notify her of the purpose of the visit.

LPA interviewed staff, collected and reviewed pertinent documents and walked through the facility.
It is alleged that uncleared staff members are allowed to work in the facility. LPA reviewed the staff roaster which was consistent with information located on the Guardian website. LPA researched and found that each staff member is also associated to the facility as required by regulation. The information was further verified by comparing the Administrator Certificate numbers with those posted on the website. Additionally,
LPA reviewed staff files of four, (4). 4 out of 4 employee files included fingerprint clearances and criminal background checks. Furthermore, each staff file included up to date training as regulated.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 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.

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 56-AS-20231004142538

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR VI	FACILITY NUMBER: 366424424
	VISIT DATE: 10/30/2023

NARRATIVE

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It is alleged that the facility does not have a qualified Administrator. LPA located three, (3) Administrator Certificates inside staff files. This information is also reflected on the Community Care Licensing Administrator Certification website. Each of Administrator Certificates were both current and in good standing.
LPA unable to locate any evidence that the Administrator Certificates were ever in question or lapsed.

Based on record reviews and observations, we have found the complaint allegation(s) is/ are unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. An exit interview was conducted where this report was reviewed, discussed then provided to the Facility Representative.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 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

LIC9099 (FAS) - (06/04)

Page: 4 of 4