Genesis Manor IV

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro and Licensing Program Manager conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Elyssa Markie, Administrator, and explained the reason for the visit. The facility is licensed to serve six (6) residents, age 60 and over, and is approved to care for up to six (6) bedridden residents. The facility is also approved to retain up to three (3) hospice residents. There was (3) resident under hospice care during inspection. Facility Tour & Observations: Personal Rights postings (LIC 613C and Ombudsman), Complaint Poster (PUB 475), and nondiscrimination notice were observed in a common area. Residents had access to personal space, privacy, and adequate storage. No firearms/weapons were present. Physical Plant The facility is located in a residential neighborhood and is a single-story home consisting of five (5) resident bedrooms, two (2) bathrooms, a living room, kitchen, dining area, attached garage, front yard, and backyard. The attached garage contains two built-in caregiver quarters. LPA observed five (5) resident bedrooms, with one (1) bedroom vacant at the time of the visit. All bedrooms observed contained the required furnishings, including a bed, mattress, linens, dresser, chair, and adequate lighting. Cleaning supplies and other toxic substances were observed to be inaccessible to residents and secured in locked cabinets located in the kitchen and restrooms. Bathrooms were clean and equipped with required grab bars in the showers and near toilets, as well as non-skid mats. (continued on 809C) Hot water temperature measured 110.9°F in Bathroom (1) and 113.2°F in Bathroom (2), which is within the required range of 105°F–120°F. Extra linens and towels were available and stored in hallway cabinets. Smoke and carbon monoxide detectors were tested and found to be operational. A fire extinguisher was observed near the dining room area and medication cabinet. No bodies of water were present on the premises. The backyard contained shaded seating for residents. Passageways and exits were observed to be clear and unobstructed. Food Service Refrigerators/freezers were maintained at proper temperatures (refrigerators maximum of 40 degrees°F and freezer 0-degreeºC ) with sufficient supply of 2-day perishable and 7 days non-perishable food. Fresh produce, proteins, and dry goods were stocked. Knives and cleaning supplies were observed in a locked kitchen cabinet under the sink. Health-Related Services & Records Three (3) resident files were reviewed and were found to contain current required documentation, including Admission Agreements, Pre-Placement Appraisals, signed consents, Needs and Service Plans, Physician’s Reports documenting TB results and ambulatory status, and Resident Rights acknowledgments. Three (3) residents’ medications were reviewed. Medications were observed to be centrally stored in a locked closet located in the living room. During the medication review, LPA observed that Resident 1 (R1) had medications requiring refills that had not yet been obtained. Disaster Preparedness Last fire/earthquake drill was conducted in February 06, 2026, with logs available. LIC 610D Emergency Disaster Plan was available and updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed. Infection Control Plan was updated. Personnel Records & Training Three (3) staff files were reviewed and included criminal record clearances, CPR/First Aid, required training and TB screenings. Administrator Certificate for Elyssa Markie was valid through September 15, 2026. Insurance Liability insurance was in compliance with an expiration date of June 15, 2026. An exit interview was conducted with the Administrator Elyssa Markie. During the inspection, deficiencies were observed and cited on the attached LIC 809D/809C in accordance with Title 22, Division 6 regulations. A copy of this report, LIC 809D/809C, and appeal rights will be provided via email.the state’s words, verbatim · CDSS document, Feb 9, 2026

The state marks this report as 6 pages; the online copy we transcribed has 4. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced annual inspection visit on 03/17/2025 and was greeted by Caregiver Eustaquio Canon. Administrator Elyssa Markie arrived shortly after. LPA Ramirez explained the purpose of the visit. The facility is located on a residential street and is a single store dwelling. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Physical Plant and Environment safety: Disinfectants, cleaning solutions, poisons and other items that could pose a danger if readily available to residents, were observed to be inaccessible to residents. LPA Ramirez observed carbon monoxide detectors and smoke alarms in hallways. LPA Ramirez inspected five (5) resident rooms. All resident bedrooms contained required furniture, linens and lighting. Water temperatures in all grooming and bathing areas were measured to be with 105 – 120 degrees F. LPA Ramirez observed grab bars near toilets and inside shower. LPA Ramirez observed no-slip mat in showers. Bathroom#1 was observed to be wheelchair accessible. Video surveillance was observed in common areas. Food Service: LPA Ramirez observed sufficient supply of non-perishable for one week and perishable foods for a minimum of two days in the facility kitchen area. Soaps, detergents, and cleaning compounds were observed to be stored away from food supplies. Freezers and refrigerators were observed to be clean and within temperatures of 0-degree F (-17.7 degree C), and refrigerators with maximum temperature of 40-degree F. (4 degree C). Planned Activities: LPA Ramirez observed board games, magazines, and other activities for residents. Residents Rights-Information: LPA Ramirez observed the following postings in common areas throughout the facility: Complaint Poster (PUB 475), personal rights, and nondiscrimination notice. LPA Ramirez observed facility land line. Disaster Preparedness: The facility has the Emergency Disaster Plan (LIC610D/9 pages) in place. Last documented emergency drills were conducted on 01/01/2025. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply located in pantry. See 809-C Residents with Special Needs: No large bodies of water were observed LPA Ramirez observed signs posted indicating “No smoking - Oxygen in Use” in various locations of the facility. LPA Ramirez observed several oxygen tanks in resident rooms secured in stands. Knives, sharps or other items that could pose a danger to residents with dementia, were observed to be inaccessible. Auditory devices were observed to be in working order. Health Related Services/Incidental Medical Services: The medications are centrally stored in the medication closet and in bubble packs and/or original containers. LPA Ramirez observed Centrally Stored Medication and Destruction Record. The facility provides incidental medical services. Staffing: Administrator Certificate for Elyssa Markie 09/15/2026. Staff employed are over the age of 18 and are fingerprint cleared and associated to the facility. Personnel Records Training: Staff files are maintained at the facility. LPA Ramirez observed required annual training, CPR and First Aid for three (3) out of the three (3) personnel record reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for three (3) out of the three (3) personnel record reviewed. Infection Control: There are using appropriate hand hygiene and wearing gloves while assisting clients. Staff are cleaning and disinfecting often for high touched surfaces. Facility has an Infection Control Plan in place. Operational Requirements: The fire clearance is approved for six (6) bedridden residents and may retain three (3) hospice residents. There are currently three (3) residents on hospice care. Resident Records/Incident Reports: LPA reviewed resident records for six (6) residents in care. Resident records are maintained at the facility. Admission Agreement, Physician's Report (including T.B and Ambulatory Status), Consent for Medical Treatment, Preplacement Appraisal Information, Resident Pre-Appraisal, Care Plan/Appraisal/Needs and Services Plan, Resident Rights were observed. No deficiencies were observed during this visit. Exit interview conducted. A copy of this report was provided via email.the state’s words, verbatim · CDSS document, Mar 17, 2025

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent Annual Required Visit on 03/22/2024. LPA Ramirez conducted initial annual required visit on 03/18/2024. LPA was met by Caregiver Arturo Bastes and explained the purpose of the visit. Back-up Administrator Alaina Hendrick arrived shortly after to assist with inspection. Facility is licensed to clients over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for three (3) hospice residents. LPA Ramirez observed video surveillance in common areas. LPA requested and obtained a copy of Personnel Report (LIC 500) and Resident Roster (LIC 9020). Emergency Drills/Emergency Disaster Plan/First Aid Kit: LPA Ramirez observed Emergency & Disaster Plan (LIC 610E) during inspection. Last two (2) fire drills were conducted on 03/03/24 and 12/11/23. LPA Ramirez observed a First Aid kit in facility hallway. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher: LPA observed carbon monoxide in hallways and smoke detectors were observed to be operable. Personnel Records: Personnel records are maintained at facility. LPA Ramirez reviewed staff files for three (3) staff. LPA Ramirez observed Administrator’s certificate for Elyssa N Markie with an expiration date of 09/15/2024. First Aid & CPR Certificate, Fingerprint Clearance/ Exemptions, Personnel Record/Job Application, Health Screening, Employee Rights, TB Test, and Initial/Annual Training Verification were observed. Resident Records: Four (4) resident files were reviewed. Admissions Agreement, Medical Assessment, Consent Forms, Appraisal and Needs and Services plan, I.D and Emergency Information, TB Test, Centrally Stored Medication Record, and Personal Rights Form were observed. Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan. No deficiencies were observed . Exit interview was conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 22, 2024

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required Visit on 03/18/2024 at 2:40 pm. LPA was met by Caregiver Natividad "Ida" Almodovar and explained the purpose of the visit. Facility is licensed to clients over 60 years old. The facility cares for elderly residents with dementia and is allowed to care for three (3) hospice residents. LPA Ramirez observed video surveilance in common areas. LPA requested and obtained a copy of Personnel Report (LIC 500) and Resident Roster (LIC 9020). LPA OBSERVATIONS: Tour was given at 2:55 pm. The facility is located on residential street. The facility consists of five (5) bedrooms, two (2) bathrooms, live in staff room located in garage, kitchen, dining room, living room, linen closet, attached garage, open front yard and enclosed backyard. Kitchen: LPA observed kitchen to be clean and appliances appeared to be in working order. LPA observed sufficient 2 days of perishables and 7 days of non-perishables. Kitchen sink water temperature was measured at 110.1 degrees F. Sharps were secured in cabinet and inaccessible to residents. Dining Room/Living Room: Dining room area was clean, and LPA observed a table with 5 chairs. Living room area had 2 couches for seating. Signs promoting social distancing and cough/sneeze etiquette were observed throughout this area. LPA observed emergency food supply and emergency water supply located in cabinet. LPA Ramirez observed Long-Term Care Ombudsman poster in this area. Linen Closet: Contained plenty of linens, towels, and hygiene products. Resident Rooms 1 - 5: All contained the required furnishings, linens and were observed to be clean. Attached Garage: Contained a washer and dryer. LPA observed PPE supplies. LPA Ramirez observed room in garage for live in staff. LPA Ramirez observed facility sketch which indicates this observation. Due to time constraints, LPA Ramirez will returm to complete annual inspection. No deficiencies were observed at this time. A copy of this report was provided.the state’s words, verbatim · CDSS document, Mar 18, 2024