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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880543
Report Date: 09/30/2021
Date Signed: 09/30/2021 03:41:27 PM

Unsubstantiated


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
09/27/2021 and conducted by Evaluator Javier Prieto
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20210927110431
FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: DATE:
09/30/2021
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Na (Sandy) Zhao, and Tracy FieldsTIME COMPLETED:
03:31 PM
ALLEGATION(S):
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Resident sustained pressure injuries while in care
Staff are mismanaging residents medication
Staff did not seek medical attention for resident
Staff threatened resident
Staff left resident in soiled diapers for extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Javier Prieto and Rohit Lama arrived to the facility to conduct a complaint investigation regarding allegations that: resident sustained pressure injuries while in care, staff are mismanaging residents medication, staff did not seek medical attention for resident, staff threatened resident, and staff left resident in soiled diapers for extended period of time. LPAs Prieto and Lama met with staff Tracy Fields and Licensee Na (Sandy) Zhao, via facetime. LPAs interviewed Resident number 1 (R1), staff, and medical staff and obtained documentation. Interview with LVN and document reviewed does not reveal and pressure injuries on R1. Interview with LVN and documents reviewed reveal that medications are being given as prescribed. Presence of LVN show that R1 is receiving appropriate medical care. R1 testimony reveals that staff are treating her well and R1 did not indicate any threats from staff. Interview with R1 states that R1 was not left in soiled diapers for an extended period of time and LVN interview did not indicate physical evidence of R1 being left in diapers for an extended period of time.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
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 2
Control Number 18-AS-20210927110431
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: 09/30/2021
NARRATIVE
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Based on the information obtained there is not enough evidence that resident sustained pressure injuries while in care, staff are mismanaging residents medication, staff did not seek medical attention for resident, staff threatened resident, and staff left resident in soiled diapers for extended period of time. Therefore, the allegations are deemed UNSUBSTANTIATED at this time. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with LPAs, staff Tracy Fields, and Miss Zhao, via Facetime. Licensee agrees to have staff Fields sign on her behalf. A copy of this report is left with this facility.

SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Javier Prieto
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2