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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 366424424
Report Date: 04/27/2022
Date Signed: 04/27/2022 04:05:13 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220425160558
FACILITY NAME:GENESIS MANOR VIFACILITY NUMBER:
366424424
ADMINISTRATOR:DAVID MARKIEFACILITY TYPE:
740
ADDRESS:6936 AMETHYST AVENUETELEPHONE:
(909) 262-9802
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 6DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Administrator, Marya AlpertTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Due to lack of supervision residents engaged in an inappropriate interaction
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegation listed above. LPA met with Administrator Marya Alpert.

The allegation states that because there was an instance of lack of supervision, Resident #1 (R1) and Resident #6 (R6) engaged in inappropriate activity. During interviews with Staff #1 (S1) and Staff #2 (S2), S1 and S2 both admitted that although it was consensual, R1 and R6 did in fact engage in inappropriate behavior. Interview with the administrator also revealed that althoguh concentual, there was an instance of inappropriate behavior. Based on the evidence gathered during investigation, the above allegation is Substantiated. A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Section 87705(c)(4) is being cited on the attached LIC9099D. Refer to LIC 9099-D dated 04/27/2022 for deficiencies cited.
*****CONTINUED ON LIC 9099-C*****
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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-20220425160558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424
VISIT DATE: 04/27/2022
NARRATIVE
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CONTINUED FROM LIC 9099

A civil penalty will be assessed for an amount of $100 per day per resident retroactively for the first 15 days if the operator fails to correct the deficiency on the plan of correction (POC) date. Additional civil penalties may accrue after that.

LPA conducted an exit interview where a copy of this report was discussed and provided to Administrator Marya Alpert.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/25/2022 and conducted by Evaluator Rohit Lama
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20220425160558

FACILITY NAME:GENESIS MANOR VIFACILITY NUMBER:
366424424
ADMINISTRATOR:DAVID MARKIEFACILITY TYPE:
740
ADDRESS:6936 AMETHYST AVENUETELEPHONE:
(909) 262-9802
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY:6CENSUS: 6DATE:
04/27/2022
UNANNOUNCEDTIME BEGAN:
01:52 PM
MET WITH:Administrator, Marya AlpertTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff failed to provide a safe environment for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rohit Lama conducted an unannounced visit to initiate a complaint investigation and deliver the findings for the allegation listed above. LPA met with Administrator Marya Alpert.

The allegation states that facility staff did not provide a safe environment in the facility due to the fact that staff would be asleep and not provide supervision. LPA Lama interviewed Residents #1 (R1), #2 (R2), #3 (R3), #4 (R4), #5 (R5), and #6 (R6). LPA also interviewed Staff #1 (S1) and #2 (S2). R2 was non-verbal. R1, R3, R4, R5, and R6 stated that staff always met their needs in a timely manner, that they felt safe in the facility, and that they have never seen the staff asleep. S1 and S2 stated that they felt there was enough staff in the facility to meet the needs of the residents and that they believed the residents are safe in the facility. Based on observations made and interviewes conducted, the allegation that the staff failed to provide a safe environment for residents is Unsubstantiated. A finding that the complaint is Unsubstantiated means that 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.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
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-20220425160558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/27/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
05/11/2022
Section Cited
CCR
87705(c)(4)
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Care of Persons with Dementia: Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional,
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The Administrator will by Plan of Correction (POC) due date provide in-service training to care givers regarding Providing Care to Residents with Dementia. Administrator will provide proof of training to LPA in the form of a scanned document that states the.
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 safety and health care needs as identified in his/her current appraisal. This regulation was not met as evidenced by interviews with S1 and S2 that residents engaged in inappropriate behavior. This poses as a potentiatl health and safety risk to residents in care.
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 trainnig provided, the date, printed names and signatures of all trainees by POC due date
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Rohit LamaTELEPHONE: 951-217-9826
LICENSING EVALUATOR SIGNATURE:

DATE: 04/27/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4