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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306005646
Report Date: 12/08/2021
Date Signed: 01/27/2022 10:23:41 PM

Document Has Been Signed on 01/27/2022 10:23 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GENESIS SENIOR LIVING IIFACILITY NUMBER:
306005646
ADMINISTRATOR:GARSIN-PABALE, NOIMEFACILITY TYPE:
740
ADDRESS:129 MOUNTAIN VIEW DRIVETELEPHONE:
(657) 210-4454
CITY:TUSTINSTATE: CAZIP CODE:
92780
CAPACITY: 6CENSUS: 5DATE:
12/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
04:35 PM
MET WITH:Noime Garsin-PabaleTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Lydia Martinez made an unannounced visit to the facility for the purpose of conducting a Required - 1 Year Annual inspection, with an emphasis on Infection Control due to the COVID-19 pandemic. LPA Martinez met with and was granted entry into the facility by Staff Remy Jardin. Staff Jardin confirmed there are currently no cases or exposures of COVID-19 within the facility. LPA was screened upon entry into the facility. Administrator Noime Garsin-Pabale arrived shortly after.

LPA observed the required Department posting on COVID-19 precautions at entrance of facility. There is a sign-in procedure in place and hand sanitizer for use. LPA observed that all staff were wearing face mask. The facility has an approved Mitigation Plan on file with CCLD. There are 5 residents present during this visit, of which 2 are receiving Hospice Services. LPA conducted a tour of the facility and made observations pertaining to the facility's Infection Control measures. LPA toured all resident rooms, all rooms were within regulations. Residents appeared clean and content. Restrooms observed contained soap, toilet paper and paper towels and had the proper hand washing signs posted. Facility has operating smoke and carbon monoxide detectors. Facility has Fire Extinguishers which was charged. The facility was equipped with sufficient hand hygiene supplies, cleaning and disinfecting provisions. Personal Protective Equipment (PPE) supply is available. The facility monitors the residents regularly for any COVID-19 symptoms/change of condition and documents. Facility has required Emergency Disaster Plan posted, and a secured location for resident's medication and files. Facility has 30 days supply of medications for the residents. Resident files were reviewed. Residents emergency contact information and Physicians reports are current.

Based on observations made during today’s inspection, no deficiencies are being cited per Title 22, Division 6, of the California Code of Regulations. LPA reviewed this report with AD and a copy will be emailed.
SUPERVISORS NAME: Marina Stanic
LICENSING EVALUATOR NAME: Lydia Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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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