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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 03/25/2022
Date Signed: 03/25/2022 12:41:01 PM

Document Has Been Signed on 03/25/2022 12:41 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 2DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:51 AM
MET WITH:Victor Vidrio - Caretaker TIME COMPLETED:
12:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. Upon entry LPA Gardner met with Caretaker Victor Vidrio who confirmed that there are currently no cases/exposures of COVID-19 within the facility. At the time of visit there were two (2) staff, and two (2) residents present. S1 spoke to LPA Gardner in broken English. S1 stated that they did not understand LPA Gardner. S1 requested that LPA Gardner speak into a cell phone on a translator application. S1 read the translator application, then spoke into the translator application to respond to LPA Gardner. LPA Gardner called the licensee and notified them they need to come to the facility to complete the visit or send another staff member who could speak to LPA Gardner with no communication issues. Licensee Na. Zhoa did not come to the facility, so LPA Gardner completed the visit with S1. The facility will be issued Technical Assistance Advisory note for not having someone at the facility capable of communicating without issues.

Upon observation and interview, LPA Gardner discovered that S2 is working at the facility without having criminal background clearance. S2 has been working at the facility for one (1) year. The facility will be issued a citation for S2 not having a criminal background clearance, as well as a $500-dollar civil penalty.

LPA Gardner requested to view staff files for S1, LPA Gardner was notified there was not a staff file for S1. The facility will be issued a citation for having a staff file for S1. S1 started creating a file during todays visit once LPA Gardner notified them it was needed for review.

...Continued on LIC809C...
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 03/25/2022
NARRATIVE
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...Continued from LIC809...

Upon review LPA Gardner discovered the administrator certificate is expired. The facility will be cited for not having a valid administrator for the facility.

LPA Gardner went over COVID-19 best practices for infection control and prevention with Mr. Vidrio. Residents have hand sanitizer available to them and the bathrooms were stocked with hand soap and paper towels. LPA Gardner observed the facility to have multiple postings throughout the facility for cough etiquette, proper hand washing procedure, and social distancing. LPA Gardner requested to inspect the facility's Personal Protective Equipment (PPE) supply; Mr. Vidrio was unsure where the PPE was located in the facility. LPA Gardner was unable to verify if the facility has a 30-day supply of PPE items such as gloves, face shields, gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA Gardner discussed obtaining a full 30-day supply of PPE, as well as creating a cart, or similar, to have a supply of PPE ready that would be dedicated for isolation room, along with a trash can to put inside and outside of an isolation room. LPA Gardner inquired as to if staff have been fit tested for N95 masks, and Mr. Vidrio was unsure if they had been fit tested yet. LPA Gardner will be issuing a Technical Assistance Advisory Note during today's inspection for staff not being fit tested for N95 masks and for not having a 30-day supply of PPE. All residents and staff are practicing all other COVID-19 precautions, which minimize the risk of them contracting COVID-19.

Based on the observations made during today’s visit, three (3) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Mr. Vidrio, along with a copy of the TA Advisory Notes, LIC809C, LIC809Ds, LIC421BG, and appeal rights
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2022 12:41 PM - It Cannot Be Edited


Created By: Ryan Gardner On 03/25/2022 at 11:22 AM
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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
Administrator - Qualifications and Duties. (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person. The administrator shall have sufficient freedom from other responsibilities and shall be on the premises a sufficient number of hours to permit adequate attention to the management and administration of the facility as specified in this section. When the administrator is not in the facility, there shall be coverage by a designated substitute who shall have qualifications adequate to be responsible and accountable for management and administration of the facility as specified in this section. The Department may require that the administrator devote additional hours in the facility to fulfill his/her responsibilities when the need for such additional hours is substantiated by written documentation. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and records not available for LPA review, the licensee did not comply with the section cited above by not having proof of a current administrator which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/15/2022
Plan of Correction
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The licensee agreed to send valid administrator documentation to licensing by planned POC date. The licensee agreed to read regulation 87405 entirely. The licensee agreed to send a self-certify letter to licensing detailing that the regulation was read and is understood.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2022 12:41 PM - It Cannot Be Edited


Created By: Ryan Gardner On 03/25/2022 at 11:49 AM
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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(g)
Personnel Records. (g) All personnel records shall be maintained at the facility and shall be available to the licensing agency for review.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a staff personnel record for S1 for licensing to review which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/28/2022
Plan of Correction
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The licensee has agreed to read regulation 87412 entirely. The licensee has agreed to send a self-certify letter to licensing that the regulation has been read and is understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/25/2022 12:41 PM - It Cannot Be Edited


Created By: Ryan Gardner On 03/25/2022 at 12:00 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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(g)(1-3)
Personnel Requirements – General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (1) Obtain a California clearance or a criminal record exemption as required by law or Department regulations or (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or (3 )Request and be approved for a transfer of a criminal record exemption, as specified in Section 87356(r), unless, upon request for a transfer, the Department permits the individual to be employed, reside or be present at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by allowing S2 to work in the facility without having a criminal background clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/26/2022
Plan of Correction
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The licensee agrees to not allow S2 to work in the facility until they obtain a criminal background clearance. The licensee agrees to read regulation 87411 entirely. The licensee agrees to send licensing a self-certify letter that the regulation has been read and is understood.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME:Karen Clemons
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 03/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022


LIC809 (FAS) - (06/04)
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