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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880810
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:28:46 PM

Document Has Been Signed on 11/02/2023 04:28 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GREEN MERRYLANDS MURRIETA HOMEFACILITY NUMBER:
331880810
ADMINISTRATOR:BRANDON MARQUEZFACILITY TYPE:
740
ADDRESS:40052 DAPHNE DRIVETELEPHONE:
(909) 994-6204
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 1DATE:
11/02/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Staff, Maritza Alfaro MendozaTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to continue the required annual. LPA was granted entry and met with Staff, Maritza Alfaro Mendoza, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (1) clients present.

Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.



Health Related Services/ Incidental Medical Services: Resident Medication was reviewed during the visit. All medication for (1) resident had required labeling and was accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 10/11/2023.

An exit interview was conducted where this report where reviewed and provided to Staff, Maritza Alfaro Mendoza.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2023
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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