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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366426141
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:04:50 PM

Document Has Been Signed on 10/30/2023 04:04 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:HALCYON PLACE IFACILITY NUMBER:
366426141
ADMINISTRATOR:MARYA ALPERTFACILITY TYPE:
740
ADDRESS:6947 KIRKWOOD AVENUETELEPHONE:
(951) 818-6667
CITY:ALTA LOMASTATE: CAZIP CODE:
91701
CAPACITY: 6CENSUS: 4DATE:
10/30/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:45 PM
MET WITH:Eva Tancinco, CaregiverTIME COMPLETED:
04:00 PM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived at the Genesis Manor Residential Care for the Elderly to obtain signatures on an Amended Report. LPA met with staff, introduced self and stated purpose of the visit. LPA obtained signatures and completed report.

An exit interview was conducted where this report was discussed and provided to facility representative.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2023
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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