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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880543
Report Date: 06/28/2021
Date Signed: 06/28/2021 01:23:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2020 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200729165717
FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:CARIE RAJKUMARFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(818) 267-0352
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 3DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Tracy FieldsTIME COMPLETED:
01:32 PM
ALLEGATION(S):
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Facility abandoned resident at the hospital
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to deliver the finding of the above allegation. LPA met with caregiver Tracy Fields. LPA spoke with the administrator over the phone.

The investigation consisted of file review and interviews with relevant parties. The allegation indicates that on 7/29/20 the facility abandoned Resident 1 (R1) at the hospital after he/she was ready to be discharged. LPA was informed on 7/28/20 R1 started exhibiting COVID-19 symptoms. The facility staff called 911 and R1 was transported to the local hospital. R1 was tested for COVID-19 and the result was still pending. R1 was ready to be discharged that same day so he/she returned to the facility and was placed in isolation. On the following day, 7/29/20, the facility was informed that R1 tested positive for COVID-19. The facility staff called 911 and R1 was transported again to the local hospital. R1 was ready to be discharged that same day but the facility refused to take the resident back. LPA spoke with the licensee who stated that the facility could not accept the resident back due to the potential of insufficient staffing (i.e. staff who were not willing to
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20200729165717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 06/28/2021
NARRATIVE
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work with COVID-19 positive residents). This poses an immediate health & safety risk to the resident in care. R1’s responsible party had to make arrangements and have the resident transferred to a different facility.

Based on LPA’s observations and interviews, which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 & Chapter 8) is being cited on the attached LIC9099D.

An exit interview was conducted where this report, LIC9099D, and appeal rights were discussed and provided to the caregiver.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 18-AS-20200729165717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2021
Section Cited
CCR
87468.2(a)(20)
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87468.2 ADDITIONAL PERSONAL RIGHTS OF RESIDENTS IN PRIVATELY OPERATED FACILITIES (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following
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The licensee shall review the regulation section and submit a statement of understanding. Proof will be submitted to the Department by 6/29/21.
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personal rights: (20) To be protected from involuntary transfers, discharges, and evictions. A licensee shall not involuntarily transfer or evict residents for reasons other than those permitted by state law or regulations and shall comply with all eviction and relocation protections for residents.
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DEF CONT'D For purposes of this paragraph, "involuntary" means a transfer, discharge, or eviction that is initiated by the licensee, not by the resident. This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure R1 was protected from involuntary discharge. On 7/29/20 R1 was ready to be discharged from the hospital. Interviews reported that the facility refused to take the resident back. R1’s responsible party had to make arrangements & transfer the resident to a different facility.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/29/2020 and conducted by Evaluator Christine Le
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20200729165717

FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:CARIE RAJKUMARFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(818) 267-0352
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 3DATE:
06/28/2021
UNANNOUNCEDTIME BEGAN:
12:37 PM
MET WITH:Tracy FieldsTIME COMPLETED:
01:32 PM
ALLEGATION(S):
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Facility is neglecting residents
Facility is not providing adequate food service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Christine Le conducted an unannounced visit to the facility to deliver the findings of the above allegations. LPA met with caregiver Tracy Fields. LPA spoke with the administrator over the phone.

The investigation consisted of file review and interviews with relevant parties. The first allegation indicates that the facility is neglecting to take care of the residents from 7PM to 7AM. LPA was informed that there is live-in staff that provide care and supervision at night. LPA reviewed the staff schedule and observed 24/7 coverage. LPA spoke with the live-in staff who advised that he/she is available and the residents are able to ask for assistance if needed. LPA spoke with a number of residents who reported that staff are available at night and did not recall times where staff were not responsive to their care needs. The second allegation indicates that the facility does not provide snacks after meals. LPA reviewed the facility menu and observed that three (3) snacks are served daily. Snacks are generally served after every meal. LPA conducted interviews with staff and residents who reported that the food service is of good quality and quantity.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20200729165717
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 06/28/2021
NARRATIVE
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Examples of snacks include fruits, vegetables, and desserts.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated at this time.

No deficiencies were cited during this visit. An exit interview was conducted where this report was discussed and provided to the caregiver.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Christine Le
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 5