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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 08/24/2023
Date Signed: 08/24/2023 04:28:28 PM

Document Has Been Signed on 08/24/2023 04:28 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: 5DATE:
08/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:21 PM
MET WITH:Care Giver Oslvado Nunes TIME COMPLETED:
04:35 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 was granted entry to the facility. LPA was accompanied by Oslvado Nunes.

Due to technically difficulties LPA will return later to complete annual.

An exit interview was conducted, and this report (LIC809) was discussed and provided to Oslvado Nunes

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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