<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880543
Report Date: 08/04/2023
Date Signed: 08/04/2023 10:08:52 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/14/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221214145741
FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 5DATE:
08/04/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Osvaldo Nunes Aldrate "Aldrete"- CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff are not following resident's care plan.
Staff are providing improper testing assistance to resident in care.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Caregiver Osvaldo Nunes Aldrate "Aldrete". The investigation on 12/22/2022 consisted of resident interviews, staff interviews, document review, and a facility tour.

For allegation, Staff are not following resident's care plan:

Interviews with staff and document review revealed that the facility did not update R1’s Appraisal/Needs and Services plan, LIC 625, to include R1’s home health needs and R1’s glucose testing needs. Interviews with staff revealed that the staff were verbally informed on how to provide care for R1. The facility did not have a copy of R1's home health care plan at the facility. LPA contacted R1's home health company to obtain documents and verify care was being provided by the home health company. The facility did not follow R1's care plan correctly due to it not being updated with R1's needs.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
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 56-AS-20221214145741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 08/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For allegation, Staff are providing improper testing assistance to resident in care:

Interviews with staff and document review revealed that the facility staff were using diabetic glucose test strips to test R1’s blood glucose level. R1 was not able to perform the testing on their own. The facility staff were testing R1’s glucose level by pricking R1’s skin and placing the blood on a test strip. LPA reviewed a daily log of R1’s glucose testing that was done by the facility staff. The facility staff is not allowed to test R1’s blood glucose level due to them not being skilled professionals.

Based on the evidence gathered during the investigation, the two (2) allegations listed above are deemed SUBSTANTIATED. A finding that the complaints are SUBSTANTIATED means that the allegations are valid because the preponderance of evidence the standard has been met.

During today’s visit, two (2) deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) and LIC9099D form was discussed and provided to Caregiver Osvaldo Nunes Aldrate "Aldrete", along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20221214145741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/05/2023
Section Cited
CCR
87628(a)
1
2
3
4
5
6
7
87628 Diabetes.(a) The licensee shall be permitted to accept or retain a resident who has diabetes if the resident is able to perform his/her own glucose testing with blood or urine specimens, and is able to administer his/her own medication including medication administered orally or through injection, or has it administered by an appropriately skilled professional.
1
2
3
4
5
6
7
The licensee has agreed to read regulation 87628 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to accept residents that can administer their own glucose testing and or hire a qualified professional to...
8
9
10
11
12
13
14
Based on interview and document review, the licensee did not comply with the section cited above evidenced by unskilled staff administering glucose testing to a resident which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
administer glucose testing.The licensee has agreed to train the facility staff on what services can be provided to diabetic residents and send proof of the training to LPA. The POC is due by 8/5/2023.
Type A
08/05/2023
Section Cited
CCR
87609(b)(2)
1
2
3
4
5
6
7
87609 Allowable Health Conditions and the Use of Home Health Agencies
(b) Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met:
(2) The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.
1
2
3
4
5
6
7
The licensee has agreed to read regulation 87609 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed that moving forward all residents under the care of home health will have a care plan in place that...
8
9
10
11
12
13
14
Based on interview and document review, the licensee did not comply with the section cited above evidenced by not having a care plan to support a resident’s home health needs which poses an immediate health, safety, or personal rights risk to persons in care.
8
9
10
11
12
13
14
supports the residents home health needs. The POC is due by 8/5/2023.
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: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 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
12/14/2022 and conducted by Evaluator Ryan Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20221214145741

FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:PENDINGFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 6DATE:
08/04/2023
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Osvaldo Nunes Aldrate "Aldrete"- CaregiverTIME COMPLETED:
10:20 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not provide proper bed accommodations to resident in care.
Staff did not safeguard resident's personal belongings.
Staff did not inform resident's authorized representative of resident's incident.


INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Ryan Gardner made an unannounced visit to the facility to issue findings for the allegations listed above. LPA stated the purpose of the visit and was granted entry and met with Caregiver Osvaldo Nunes Aldrate "Aldrete". The investigation on 12/22/2022 consisted of resident interviews, staff interviews, document review, and a facility tour.

For allegation, Staff did not provide proper bed accommodations to resident in care:

It was alleged that resident (R1) was not sleeping on a bed provided by an outside medical provider. Interviews with staff revealed that R1 moved out of the facility on 12/15/2022. LPA conducted a facility tour on 12/22/2022, at this time R1’s bed accommodations could not be verified due to the resident no longer living at the facility. Interviews with staff revealed that the staff denied that R1 was not using the proper bed and stated R1 was using the correct bed provided by the outside medical provider.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 56-AS-20221214145741
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 08/04/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
For allegation, Staff did not safeguard resident's personal belongings:

It was alleged the R1’s clothing was missing and not returned to R1. Interviews with staff and document review revealed that R1 had a completed LIC621(Client/Resident Personal Property and Valuables) where personal belongings, including clothing, were logged. The staff denied taking, stealing, and or removing R1’s personal items from R1's bedroom. Document review revealed that R1 was returned all personal property during discharge from the facility. R1 was not present to interview. LPA interviewed R2, R3, R4, R5, and R6, the residents stated the facility staff has never stolen or removed personal items from their bedrooms.

For allegation, Staff did not inform resident's authorized representative of resident's incident:

Interviews with staff and document review revealed that there was no evidence of the facility not reporting an incident to R1’s authorized representative. During interviews with staff, the staff denied that an incident occurred with R1. The facility did not have documents to report an incident to R1’s authorized representative. State licensing did not receive an incident report for R1. R1 was not present to interview.

Overall, there was not enough evidence to collaborate the allegations listed above.

Based on evidence obtained during the investigation, the three (3) allegations listed above are deemed UNSUBSTANTIATED. A finding that the complaints are UNSUBSTANTIATED means 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.

During today’s visit, no deficiencies were cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC9099) was discussed and provided to Caregiver Osvaldo Nunes Aldrate "Aldrete", along with a copy of the appeal rights.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Ryan Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 08/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5