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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 07/07/2023
Date Signed: 07/07/2023 04:27:19 PM

Document Has Been Signed on 07/07/2023 04:27 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 4DATE:
07/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Brandon MarquezTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Mary Rico made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA met with Administrator Brandon Marquez and was granted entry to the facility. The facility is a five (5) bedroom, two (2), bathroom home and, with a kitchen/dining area, living room and attach garage. Licensed capacity is six (6) current census four (4). LPA was accompanied by Facility Administrator Brandon to conduct a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature. LPA inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, bathrooms were clean. LPA observed sufficient furniture. The hot water temperature tested within regulation at 122 degrees F. The facility is equipped with operating carbon monoxide alarms. Posters such as personal rights, the CCL complaint poster, and the disaster plan were posted in a common area

During tour, LPA observed bathroom light not operating, bathroom cabin broken, and LPA observed cleaning toxins in bathroom cabin without a lock. The smoke detector located in bedroom hallway is not operating. In addition, kitchen stove is not operating properly. LPA observed one (1) knife not locked. Furthermore, no planned activities were posted.

Due to time limitation, LPA was not able to complete Annual Inspection. Annual Inspection will be complete at a later time.

An exit interview was conducted where this report,LIC 809 and appeal rights was discussed and provided to the Administrator Brandon Marquez at the end of the visit

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2023
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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