198204544-2-9-2026-28-AS-GCAO-DR5TF3-20260209134051

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198204544
Report Date: 02/09/2026
Date Signed: 02/09/2026 01:41:14 PM

Document Has Been Signed on 02/09/2026 01:41 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GENESIS MANOR IV		FACILITY NUMBER:	198204544
ADMINISTRATOR/ DIRECTOR:	ELYSSA N. MARKIE		FACILITY TYPE:	740
ADDRESS:	1691 GENESSE AVENUE		TELEPHONE:	(909) 596-8903
CITY:	LA VERNE	STATE: CA	ZIP CODE:	91750
CAPACITY: 6		CENSUS: 6	DATE:	02/09/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Elyssa N.Markie, Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:50 PM

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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)

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GENESIS MANOR IV	FACILITY NUMBER: 198204544
	VISIT DATE: 02/09/2026

NARRATIVE

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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.

NAME OF LICENSING PROGRAM MANAGER: David Sicairos
NAME OF LICENSING PROGRAM ANALYST: Gabriela Castro
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/09/2026 01:41 PM - It Cannot Be Edited

Created By: Gabriela Castro On 02/09/2026 at 01:15 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GENESIS MANOR IV	FACILITY NUMBER: 198204544
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview and record review the licensee did not comply with the section cited above in one (1) out of three (3) residents did not have medication refilled which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2026
	Plan of Correction
1 2 3 4	The Licensee/Administrator agrees to ensure that all resident medications are refilled timely and maintained as prescribed. The Administrator will immediately contact the pharmacy and/or physician to obtain the required medication refills for Resident 1 (R1). Proof to be sent to LPA by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	David Sicairos
NAME OF LICENSING PROGRAM MANAGER:

	Gabriela Castro
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/09/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2026

LIC809 (FAS) - (06/04)

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