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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:40:10 AM

Document Has Been Signed on 12/22/2022 11:40 AM - 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:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 4DATE:
12/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Brandon Marquez GutierrezTIME COMPLETED:
11:47 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner conducted an unannounced case management during a visit for complaint control number 56-AS-20221214145741. LPA Gardner met with Brandon Marquez Gutierrez and explained the reason for the visit. At the time of the visit, there were four (4) residents, and two (2) staff present.

During today visit, LPA found that the two (2) staff present in the facility were not associated to the facility. Staff S1 has worked at the facility for three (3) years and Staff S2 has worked at the facility for one (1) and a half months.

Based on observations today, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations. The facility will also be issued a civil penalty totaling $1000 dollars.


An exit interview was conducted, and this report was discussed and provided to Brandon Marquez Gutierrez, along with LIC421BG, LIC 811, and a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 12/22/2022 11:40 AM - It Cannot Be Edited


Created By: Ryan Gardner On 12/22/2022 at 10:58 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/23/2022
Section Cited
CCR
87355(c)

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87355. Criminal Record Clearance. (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
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The licensee has agreed to submit a signed Criminal Background Clearance Transfer Request, LIC 9182, with a copy of the individual's: (A)Driver's license, or (B)Valid identification card issued by the Department of Motor Vehicles, or (C)Valid
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Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by not processing a criminal record transfer for S1. S1 has worked at the facility for three (3) years without being associated to the facility.
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photo identification issued by another state or the United States government if the individual is not a California resident or complete the process to transfer the employee on the guardian website by the POC due date. The POC is due by 12/23/2022.
Type A
12/23/2022
Section Cited
CCR87355(c)

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87355. Criminal Record Clearance. (c) A licensee or applicant for a license may request a transfer of a criminal record clearance from one state licensed facility to another, or from Trust Line to a state licensed facility by providing the following documents to the Department:
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The licensee has agreed to submit a signed Criminal Background Clearance Transfer Request, LIC 9182, with a copy of the individual's: (A)Driver's license, or (B)Valid identification card issued by the Department of Motor Vehicles, or (C)Valid
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Based on interview, observation, and record review, the licensee did not comply with the section cited above evidenced by not processing a criminal record transfer for S2. S2 has worked at the facility for one (1) and a half months without being associated to the facility.
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photo identification issued by another state or the United States government if the individual is not a California resident or complete the process to transfer the employee on the guardian website by the POC due date. The POC is due by 12/23/2022.
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:Efren Malagon
LICENSING EVALUATOR NAME:Ryan Gardner
LICENSING EVALUATOR SIGNATURE:
DATE: 12/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/22/2022


LIC809 (FAS) - (06/04)
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