366424424-1-22-2024-56-AS-ACON-CZQTN8-20240122135220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 366424424
Report Date: 01/22/2024
Date Signed: 01/22/2024 01:52:26 PM

Document Has Been Signed on 01/22/2024 01:52 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 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:	01/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Marietta Tecson, Caregiver		TIME COMPLETED:	02:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Genesis Manor VI facility unannounced to conduct the Annual Inspection. LPA was greeted by Caregiver, Marietta Tecson and invited inside. Staff Member Alfonsa stated she would contact the Administrator, Marya Alpert, who arrived later during the visit. The facility is a residential Home comprised of 6 bedrooms, 2 bathrooms, kitchen, dining room, backyard and attached garage. LPA conducted a general inspection, which include, but was not limited to the following: Physical Plant - The facility is approved for six, (6) residents, 1 of which may be bedridden. There is a Hospice Waiver in place for three, (3) residents. The current census is 6. The facility is operating in the capacity approved by Community Care Licensing (CCL). The facility is maintained in comfortable temperature. Interior pathways were free of clutter. LPA inspected 6 resident rooms. Each room included all required furniture such as sufficient storage space, lighting, mattress with proper linens, night stands, in tact windows and seating. There are 2 bathrooms. Each bathroom was equipped with handrails, non-slip grip materials, and adequate amounts of hand hygiene & paper supplies. LPA observed 3 fully charged fire extinguishers throughout the facility is also equipped with operable fire and carbon monoxide alarms. Administrator, reported the facility conducts fire/disaster drills on a monthly basis. Last drill conducted December 2023. Near the front entrance of the facility, LPA observed posters for Infection Control, Resident/Personal Rights, Emergency Contact Info. Facility Sketches with Evacuation Routes, Facility Roster, LTC Ombudsman and the Theft & Loss Policy. The facility maintains emergency food supplies and first aid kits readily available to those who may need it. Please see LIC809-C

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

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

FACILITY NAME: GENESIS MANOR VI	FACILITY NUMBER: 366424424
	VISIT DATE: 01/22/2024

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Food Service: LPA observed the facility's food supply, kept in the refrigerator, freezer and 2 pantries. LPA noted milk, bread, eggs, cheese, fresh vegetables, and a variety of frozen food accessible to residents in care. Amounts of food sufficient for the number of residents in care. Sharps and cleaning supplies are maintained securely under the kitchen sink. LPA also observed dishware, cups, and utensils were adequate in amount and properly stored.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. There were four staff members present at the time of LPA's inspection. LPA was provided staff records; LPA observed that staff members files were complete with criminal record statements, fingerprint background clearance through the department. Each staff file included proof of training in Dementia, Medication Management, Sanitation, Infection Control, Mandated Reporting, Hospice, Skin Care, First Aid and CPR, health screenings and Activities of Daily Living. Medications were observed to be kept secure along with the facility files.

Record Review: LPA reviewed, three 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA also reviewed 2 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. Administrator certificates both in good standing.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.

Based on observations, no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Licensee; signature acknowledges understanding and receipt of report and attachments.

SUPERVISOR'S NAME: Nedra Brown	TELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Amber Coleman	TELEPHONE: 951-248-0338
LICENSING EVALUATOR SIGNATURE:	DATE: 01/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024

LIC809 (FAS) - (06/04)

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