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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602851
Report Date: 08/09/2022
Date Signed: 08/09/2022 06:56:03 PM

Document Has Been Signed on 08/09/2022 06:56 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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:GENESEE VILLAFACILITY NUMBER:
197602851
ADMINISTRATOR:MARIA CLARKFACILITY TYPE:
740
ADDRESS:1441 GENESEETELEPHONE:
(323) 935-2244
CITY:LOS ANGELESSTATE: CAZIP CODE:
90019
CAPACITY: 6CENSUS: 6DATE:
08/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria ClarkTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced Annual Required / Infection Control visit to the above facility. LPA was met by Administrator Maria Clark and the purpose of today’s visit was explained.

There are currently (6) residents in the facility. The facility is a two story home/facility which consists of: living room, kitchen with dining area, office, detached laundry room, five (5) bedrooms, three (3) bathrooms. Physical plant inside and outside is in good repair.

LPA and Administrator Maria Clark toured the entire facility inside and out. The tour included a tour of the common areas, client rooms, restrooms, kitchen, dining area, and garage/storage. All client rooms were checked and observed to have the required furniture for comfort and safety such as bed frames, dressers, lamps, chairs and all rooms had sufficient lighting. Clients beds have the required linens which were observed to be in good condition at the time of the visit. All bedrooms had sufficient closet/ storage space. Bathrooms are clean, operational and were observed to be within Title 22 regulations. Toilets and water faucets worked properly. Showers were free of mold/mildew. Bathrooms had adequate lighting, and there were sufficient toiletries. Water temperature measured at 120F* which is within Title 22 Regulations. Facility temperature was comfortable throughout all of the facility. LPA observed the facility to be clean and appropriately furnished which included clear passageways inside and outside of facility. First aid kit is fully stocked with manual, smoke detectors and carbon monoxide detector were in compliance and operational. No firearms are kept in the facility and there are no bodies of water present. Medications are stored, locked and inaccessible to clients. Ample supply of perishable and nonperishable food observed, hazardous toxins and inaccessible to clients and are kept locked under the kitchen sink. Facility fire extinguishers is fully charged. Front and back yard are free of debris and/or hazards. LPA observed the facility to be in good repair at the time of the visit.

Report continues on LIC809C)

SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2022
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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: GENESEE VILLA
FACILITY NUMBER: 197602851
VISIT DATE: 08/09/2022
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The following were observed/inspected:
  • COVID-19 Infection Control Practices (including signs) were observed at the entrance of this facility, and in all common rooms bathrooms and hallways.
  • Clients are able to use a designated isolation room that will be used as isolation room if a COVID-19 positive case should arise.
  • 30 day supply of medication for clients.
  • Facility is conducting COVID-19 screening for all visitors.
  • Facility has an adequate amount of PPE and facility has enough PPE for 30+ days.
  • Clients were socially distanced according to local public health guidelines.
  • Staff responsible for direct care and supervision were observed wearing masks.
  • Hand Sanitizer: Available throughout the facility for client use.
  • High touch areas are disinfected twice a day and as needed.
  • The clients temperature's are checked and logged three a day. Morning afternoon and evening.
  • Staff temperatures are checked and logged three a day. Morning afternoon and evening.
  • Staff and clients are tested as needed for COVID-19.

Exit interview conducted, a copy of this report was provided to Administrator Maria Clark.
SUPERVISORS NAME: Stefanie Coronel
LICENSING EVALUATOR NAME: Alma Gonzalez
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2022
LIC809 (FAS) - (06/04)
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