Genesis Manor V

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Gabriela Castro conducted an unannounced required annual visit using the Compliance and Regulatory Enforcement (CARE) Tool. LPA was greeted by Anthonilla Gomez and explained the reason for the visit. Administrator David E. Markie arrived shortly thereafter. The home is licensed to serve 6 residents ages range 60 and over, six (6) non-ambulatory of which one (1) may be bedridden. Facility is approved to accept/retain four (4) hospice residents. There was one (1) resident under hospice care at the time of the 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 area and is a one-story home consisting of five (5) resident bedrooms, two (2) bathrooms, living room, kitchen, dining area, attached garage, front yard, and backyard. LPA observed four (4) resident bedrooms as one was vacant, and all contained the required furniture (bed, mattress, linens, dresser, chair, and lighting). A caregiver corridor is also present and has its own entrance accessible through the backyard. Cleaning supplies and toxic substances are inaccessible to residents in locked cabinets in the garage as well as within other locked cupboards in the kitchen and restrooms. (Continued on LIC809C) Bathrooms were clean and equipped with the required grab bars in showers and near toilets, as well as non-skid mats. Hot water measured 118.9°F in bathroom (1) and 112.8°F in bathroom (2), which is within the required range of 105°F – 120°F. Extra linens and towels were available in hallway cabinets. Smoke and carbon monoxide detectors were tested and found to be operational. A fire extinguisher was observed in the living room area near the front entrance. No bodies of water were present on the premises. The backyard provided shaded seating, and all 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 Five (5) residents files were reviewed and contained current required documents Admissions Agreements, Pre-Placement Appraisals, Consents, Needs/Service Plans, Physician’s Reports with TB/ambulatory status and Rights acknowledgments. Three (3) residents’ medications were reviewed; medications were observed to be centrally stored in a locked living room closet. MAR logs were observed to be current. Disaster Preparedness Last emergency drill was conducted on October 29, 2025, with logs available. LIC 610D Emergency Disaster Plan was available and updated. Emergency supplies (water, food, flashlights, batteries, first aid) were observed in the garage. 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 David E. Markie was valid through April 23, 2026. Insurance Liability insurance was in compliance with an expiration date of June 15, 2026. An exit interview was conducted with the Administrator David Markie. During the inspection, the facility was observed to be following Title 22, Division 6 regulations. No deficiencies were cited at this time. A copy of the report will be provided via email.the state’s words, verbatim · CDSS document, Nov 6, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced required annual inspection visit on 10/20/24 and was greeted by Caregiver Ann Gomez. 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. LPA Ramirez observed facility Hoyer lift in resident room#5 to be operational. 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 showers. LPA Ramirez observed no-slip mat in showers. Showers were observed to be wheelchair accessible. Food Service: LPA Ramirez observed sufficient supply of nonperishables 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 09/15/2024. LPA Ramirez observed facility sketches with exits and emergency exits routes throughout various locations of the facility. LPA Ramirez observed emergency food supply, and emergency water supply is in the garage. 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 hallway closet and in bubble packs and/or original containers. The facility uses the Medication Administration Record (MAR) log to document medications given. The facility provides incidental medical services. Staffing: Administrator Certificate for David Markie was received and is pending for approval. 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 four (4) out of the four (4) personnel records reviewed. LPA Ramirez observed TB testing results, Health screening, fingerprint clearance and job application for four (4) out of the four (4) personnel records 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) non-ambulatory of which one (1) may be bedridden. This facility may retain no more than four (4) hospice residents. There were zero (0) residents under hospice care during inspection. Resident Records/Incident Reports: LPA reviewed Resident files for six (6) residents in care. Resident files 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 visit. Exit interview conducted. A copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 22, 2024

Allegation investigated: Staff prevented home health agency staff from performing their duties. Uncleared staff allowed to work in the facility. Facility did not have a qualified administrator.

**Please note: This Licensing report will supersede the Licensing report dated 10/09/23, to provide additional information regarding the complaint. However, the findings will remain the same for all allegations- Unsubstantiated.** Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility to deliver a superceded complaint report. LPA Maldonado met with staff Art Bastes and explained the purpose for the visit. On 10/09/23, LPA Maldonado made an initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Licensee's Gerry Markie and Alaina Hendrick. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following records for Residents# 1-5 (R1-R5): Facesheet, Physician's Report, Pre-Placement Appraisal, and current Appraisal. LPA Maldonado also conducted interviews with Staff# 1-6 (S1-S6), Home Health LVN (LVN), and attempted interviews Residents# 1-4 (R1-R4). An interview with R5 could not be conducted due to R5 passing away in August 2023. Hospice Admission/Care Plan and Home Health records were also obtained for R5 The investigation revealed the following: (Report Continued on LIC9099-C...) Unsubstantiated Regarding allegation: Staff prevented home health agency staff from performing their duties. It is alleged that a facility staff, who is not the administrator of the facility, informed a home health agency that they were not allowed to go to any of their licensed facilities- disrupting the care of residents who reside in this home. (6) of (6) staff interviewed denied the allegation, stating that home health has never been denied entry and there are currently no residents receiving home health care at this facility. After review of (6) resident's records, it was discovered that there was only (1) resident receiving home health care during the period between March 2023 to May 2023. On 05/04/23, the resident was transferred to Hospice Care, per Hospice Admission Records. Per interview with LVN, staff of this facility never denied home health entry to this facility, to provide services to a resident. (3) of (4) residents interviewed could not corroborate the allegation. Regarding allegation: Uncleared staff allowed to work in the facility. It is alleged that a home health LVN was allowed to work at the facility without appropriate criminal background clearance and association to the facility. After review of the Facility Personnel Report Summary and the Staff Roster, it was noted that all staff have appropriate criminal background clearance and are associated to the facility. (6) of (6) staff interviewed denied the allegation and stated that LVN never workedat the facility as facility staff. LVN only provided home health services to residents. Staff also stated that new employees are fingerprint cleared and associated prior to working at the facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied and LVN stated to have never been employed as facility staff by the Licensee. Regarding allegation: Facility did not have a qualified administrator. It is alleged that a home health agency's LVN was allowed to work as an interim administrator for this facility, without having appropriate certification. (6) of (6) staff interviewed denied the allegation and stated that LVN has never worked as a staff or administrator for this facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied. LVN stated that LVN has never been employed by the facility Licensee and has never worked as a staff/administrator for this facility. Per staff roster and Facility Personnel Report, LVN is not listed as a staff at this facility and is not associated. After review of staff records, David Markie is the listed Administrator for this facility with Certificate# 6015176740, expiration date: 4/23/2024. He has met the qualifications for Administrator. Based on LPA's observations, records review, and interviews held: Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Per California Code of Regulations, Title 22, no deficiencies were observed or cited. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Jan 16, 2024 · control 28-AS-20231004142512

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced Annual Required 1-year Visit on 11/3/2023 at 12:25 pm. LPA was met by Administrator David Markie and explained the purpose of the visit. The facility is licensed to serve six (6) non-ambulatory residents over the age of 60 and provides care for elderly residents with dementia and is approved to retain four (4) residents on hospice. Currently the facility has zero (0) residents on hospice care. The facility may care for one (1) bedridden resident. LPA OBSERVATIONS: The facility is a single-story building located in a residential neighborhood with five (5) resident bedrooms, one (1) staff bedroom, two (2) shared bathrooms, kitchen, dining room, living room, front yard, backyard, and attached garage. Front Yard: Was clean and well maintained. No hazards were observed. Kitchen: LPA Ramirez observed sufficient 2 days of perishables and 7-day supply on non-perishables. LPA Ramirez observed knives and sharps located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. LPA Ramirez observed several bottles of cleaning solutions and disinfectants located in kitchen cabinet, to be inaccessible to five (5) out of five (5) residents in care. Kitchen sink water temperature was measured at 111.5 degrees F. Kitchen appliances were observed to be clean and in working order. Dining Room/Living room/: Dining room was observed to be clean and contained one table with plenty of seating. Living room was observed to have plenty of seating and lighting. Linen Closet: Contained plenty linens, towels, and hygiene products. Resident Rooms 1 - 5: LPA Ramirez observed all five (5) resident bedrooms to contain required furnishings, lighting, and linens. Bathrooms: Water temperature in two (2) resident bathrooms were within 105- 120 degrees F. Bathrooms were observed to be clean and well stocked. see 809-C for continuation. Centrally Stored Medications: Was observed to inaccessible to five (5) out of five (5) residents in care. LPA Ramirez reviewed three (3) out of the five (5) resident medications. No deficiencies were observed. Backyard: Was clean and well maintained. No hazards were observed. Plenty of shade and seating was observed. Emergency Drills: Last documented drills were conducted on 10/12/23 and 10/25/23. Carbon Monoxide Detectors/Fire Alarm/Fire Extinguisher & Emergency Disaster Plan: 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 David Markie with an expiration date of 04/23/2024. Resident Files: Five (5) resident files were reviewed. Liability Insurance & Infection Control Plan: Facility has current liability insurance on file. LPA Ramirez observed updated infection control plan. Attached Garage: LPA Ramirez observed emergency water and food supply in this area. Access to garage was observed to be inaccessible to five (5) out of five (5) residents in care. No deficiencies are being cited. Exit interview was conducted with Caregiver Campo and a copy of this report and appeals rights was provided.the state’s words, verbatim · CDSS document, Nov 3, 2023

Allegation investigated: Staff prevented home health agency staff from performing their duties. Uncleared staff allowed to work in the facility. Facility did not have a qualified administrator.

Licensing Program Analyst (LPA) V. Maldonado made an unannounced initial complaint visit to the facility for the purpose of investigating the above-mentioned allegations. LPA Maldonado met with Licensee's Gerry Markie and Alaina Hendrick and explained the purpose for the visit. During today's visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following records for Residents# 1-5 (R1-R5): Facesheet, Physician's Report, Pre-Placement Appraisal, and current Appraisal. LPA Maldonado also conducted interviews with Staff# 1-6 (S1-S6), Home Health LVN (LVN), and attempted interviews Residents# 1-4 (R1-R4). An interview with R5 could not be conducted due to R5 passing away in August 2023. Hospice Admission/Care Plan and Home Health records were also obtained for R5 The investigation revealed the following: (Report Continued on LIC9099-C...) Unsubstantiated Regarding allegation: Staff prevented home health agency staff from performing their duties. It is alleged that a facility staff, who is not the administrator of the facility, informed a home health agency that they were not allowed to go to any of their licensed facilities- disrupting the care of residents who reside in this home. (6) of (6) staff interviewed denied the allegation, stating that home health has never been denied entry and there are currently no residents receiving home health care at this facility. After review of (6) resident's records, it was discovered that there was only (1) resident receiving home health care during the period between March 2023 to May 2023. On 05/04/23, the resident was transferred to Hospice Care, per Hospice Admission Records. Per interview with LVN, staff of this facility never denied home health entry to this facility, to provide services to a resident. (3) of (4) residents interviewed could not corroborate the allegation. Regarding allegation: Uncleared staff allowed to work in the facility. It is alleged that a home health LVN was allowed to work at the facility without appropriate criminal background clearance and association to the facility. After review of the Facility Personnel Report Summary and the Staff Roster, it was noted that all staff have appropriate criminal background clearance and are associated to the facility. (6) of (6) staff interviewed denied the allegation and stated that LVN never workedat the facility as facility staff. LVN only provided home health services to residents. Staff also stated that new employees are fingerprint cleared and associated prior to working at the facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied and LVN stated to have never been employed as facility staff by the Licensee. Regarding allegation: Facility did not have a qualified administrator. It is alleged that a home health agency's LVN was allowed to work as an interim administrator for this facility, without having appropriate certification. (6) of (6) staff interviewed denied the allegation and stated that LVN has never worked as a staff or administrator for this facility. (3) of (4) residents interviewed could not corroborate the allegation. Per interview with LVN, the allegation was denied. LVN stated that LVN has never been employed by the facility Licensee and has never worked as a staff/administrator for this facility. Per staff roster and Facility Personnel Report, LVN is not listed as a staff at this facility and is not associated. Based on LPA's observations, records review, and interviews held: Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated. Per California Code of Regulations, Title 22, no deficiencies were observed or cited. Exit interview was conducted and a copy of this report was provided.the state’s words, verbatim · CDSS document, Oct 9, 2023 · control 28-AS-20231004142512