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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366424424
Report Date: 02/05/2026
Date Signed: 02/05/2026 05:48:19 PM

Document Has Been Signed on 02/05/2026 05:48 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GENESIS MANOR VIFACILITY NUMBER:
366424424
ADMINISTRATOR/
DIRECTOR:		DAVID MARKIEFACILITY TYPE:
740
ADDRESS:6936 AMETHYST AVENUETELEPHONE:
(909) 262-9802
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 5DATE:
02/05/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:24 AM
MET WITH:Marya Alpert, Administrator TIME VISIT/
INSPECTION COMPLETED:
06:03 PM
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Licensing Program Analysts (LPAs), LaVette Farlow and Michelle Echeverria arrived at the Genesis Manor VI facility unannounced to conduct the Annual Inspection. LPAs was greeted by Caregiver, Marietta Tecson and invited inside. Caregiver Mariette contacted the Administrator, Marya Alpert, who arrived later during the visit. Also, during the two other representative arrived during the visit Elyssa Kimble, and Alaina Hendricks.

The facility is a residential Home comprised of 6 bedrooms, 2 bathrooms, kitchen, dining room, backyard and attached garage, and staff living quarters. LPAs conducted a general inspection, which include, but was not limited to the following:

Physical Plant - The facility is approved for six, (6) non-ambulatory residents, 1 of which may be bedridden. There is a Hospice Waiver in place for three (3) residents. The current census is 5. LPAs reviewed residents files, toured the facility, and reviewed the facility sketch. LPAs observed two residents who are bedridden who were not in the designated bedridden approved bedroom. Fire clearance and Community Care License (CCL) granted a license for only one bedridden resident in room #6 that has an emergency exit to the backyard. Deficiencies with civil penalties cited. The facility is maintained in comfortable temperature. Interior pathways were free of clutter. LPA inspected 5 resident rooms, and one bedroom was under construction and was unable to be inspected. Each room included all required furniture such as sufficient storage space, lighting, mattress with proper linens, night stands, in tact windows and seating.
Please see LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/05/2026
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424
VISIT DATE: 02/05/2026
NARRATIVE
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There are 2 bathrooms. LPAs were only able to inspect one resident bathroom due to construction being completed on the bedroom #4 with a bathroom inside. LPAs tested the water temperature in the bathroom and kitchen. During the LPAs initial testing, the water measured at 134.5 and 136.6. LPAs were asked to conduct a retest with Elyssa. During the retest the water measured at 126.9 and Elyssa asked to aim it at a different position of the water flow and the measurement kept rising. Elyssa did not allow the measurement to be completed. Elyssa stated when she tested the water, it measured 119-122 Fahrenheit. Deficiency cited. The bathroom was equipped with handrails, non-slip grip materials, and adequate amounts of hand hygiene & paper supplies. LPAs observed cleaning supplies under the bathroom sink such as Ajax, and a liquid cleaning solution. LPAs advised Caregiver to remove and secure the supplies. A Deficiency cited. LPAs observed fully charged fire extinguishers throughout the facility is also equipped with operable fire and carbon monoxide alarms. Administrator, reported the facility conducts fire/disaster drills on a monthly basis. Last drill conducted December 2025. Near the front entrance of the facility, LPAs observed posters for Infection Control, Resident/Personal Rights, Emergency Contact Info. Facility Sketches with Evacuation Routes, Facility Roster, LTC Ombudsman and the Theft & Loss Policy. The facility maintains emergency food supplies and first aid kits readily available to those who may need it.

Food Service: LPA observed the facility's food supply, kept in the refrigerator, freezer and 2 pantries. LPA noted milk, bread, eggs, cheese, fresh vegetables, and a variety of frozen food accessible to residents in care. Amounts of food sufficient for the number of residents in care. LPA's observed some expired parmesan cheese and peanut butter in the pantry. A Deficiency cited. LPAs observed a lock on the refrigerator and pantry. LPAs inquired about the cabinet and refrigerator being locked. Administrator stated it was due to a prior resident that wanders at night. Administrator removed the locks from the refrigerator and cabinet/pantry. Sharps and cleaning supplies are maintained securely under the kitchen sink. LPA also observed dishware, cups, and utensils were adequate in amount and properly stored.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. There were three staff members present at the time of LPA's inspection.

***Please LIC-809C***
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424
VISIT DATE: 02/05/2026
NARRATIVE
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Record Review: LPA reviewed, three 3 resident files for admission agreements, updated physician reports, and needs and services plans. LPA's observed the Telecommunications Device Notification form was not signed by the resident or residents responsible party. A Technical Violation issued. LPA also reviewed 4 staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings. LPA's noticed the Administrator renewal application certificate was submitted in January 2026 which is a month after the Administrator certificate expiration date. A Technical Violation issued. LPA's audit residents medication and observed one (1) out of two (2) residents bubble did not match the number of medication issued to the number of medication in the bubble pack. LPA's observed and interviewed staff. A Deficiency cited.

Overall, the facility is clean, in good repair, and operating in safe conditions for residents in care.



Based on observations, five (5) Deficiencies, and two (2) Technical Violation cited per Title 22, California Code of Regulations. A copy of this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421IM and appeal rights were provided to Administrator, Marya Alpert.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 02/05/2026 05:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 02/05/2026 at 04:27 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)(2)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: (2) Bedridden persons

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by having two bedridden residents occupying two separate nonambulatory bedrooms which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator stated that she will create and provide a plan on accomodating the two bedridden residents and will send proof to LPA via email by POC due date.
Type A
Section Cited
CCR
87204(a)
Limitations -Capacity and Ambulatory Status
(a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the administrator did not comply with the section cited above by having two bedridden residents in a licensed and fire clearance capacity for 1 bedridden resident which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator stated she will submit a application for increase for the number of residents in care needing bedridden accommadations. Administrator agrees to submit completion of application to LPA by POC due date via email.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 02/05/2026 05:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 02/05/2026 at 04:27 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (1) Disinfectants, cleaning solutions, and poisonous substances shall be stored in areas separate from food supplies as specified in Section 87555, General Food Service Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by having cleaning supplies in the residents bathroom under the sink and not locked and secured which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Staff immediately locked chemicals after being instructed by LPA. Administrator stated that she will conduct training with staff on the regulation cited and submit proof to LPA via email by POC due date.
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the administrator did not comply with the section cited above by having an expired parmesan grated cheese and peanut butter in the pantry which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agrees to inspect all perishable and nonperishable foods and discard expired items. Administrator stated that she will submit a statement of understanding on regulation cited and submit proof to LPA via email by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 02/05/2026 05:48 PM - It Cannot Be Edited


Created By: Lavette Farlow On 02/05/2026 at 04:27 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GENESIS MANOR VI
FACILITY NUMBER: 366424424

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2026

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
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3
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Based on observation, interview and record review, the administrator did not comply with the section cited above by not maintaining an accurate centrally stored medication record where 1 out of 2 residents bubble pack did not match the number of medication remaining in the bubble from the start date the medication was administered. There was less medication available to be dispensed. The medication start date was 1/12/2026 and only one medication remained in the bubble pack. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/06/2026
Plan of Correction
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Administrator agrees to conduct a training on common error of medication and medication dispensing procedure and submit a statement of understanding and training log to LPA by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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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.
Nedra Brown
NAME OF LICENSING PROGRAM MANAGER:
Lavette Farlow
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 02/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2026


LIC809 (FAS) - (06/04)
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