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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 09/08/2023
Date Signed: 09/08/2023 03:10:59 PM

Document Has Been Signed on 09/08/2023 03:10 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:
09/08/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Sonia GuevraraTIME COMPLETED:
03:25 PM
NARRATIVE
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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 staff Sonia Guevara 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 Staff Sonia Guevara 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, night stands, storage space, bathrooms were clean. LPA observed sufficient furniture. The hot water temperature tested within regulation at 118 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 cabin broken, and medication cabin not locked.

Food Service: Non-perishable and perishable food supply is sufficient for number of clients in care. Facility has a variety of food available for clients. Dishes, cups, and utensils were also stored properly.

Care & Supervision: Facility does not sufficient staff coverage. S1 and S2 had informed LPA their Administrator does not visit their facility. S1 and S2 stated their Administrator operates six (6) other facilities. S2 informed LPA their staff only work for a short period of time and return back to their country. Licensee did not provide an updated LIC 500 and staff schedule. No documents were provided for staff coverage. Facility does not have a designated staff who meets the require qualifications. LPA discovered S1,S2,S3 are able to communicate with residents due to language barrier.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2023
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 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 01:21 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
HSC
1569.618(b)

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1569.618(b)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(b).one ..manager..designated substitute qualifications.. responsible designated substitute shall meet..This requirement is not met as evidenced by:
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Licnesee stated they will hire a designated substitue who meet the require qualifications. Licensee proof to LPA
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not having a designated substitute which poses an immediate Health, Safety or personal rights risk to persons in care.
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The POC is due by 09/09/2023
Type A
09/09/2023
Section Cited
HSC1569.618(a)

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1569.618(a)Administration and management of residential care facilities; substituted qualifications; employee scheduling.(a)... operation of the facility when the administrator is temporarily absent from the facility.
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The licensee has agreed to hire an Administractor who will be present during wokring hours. Licensee has agreed to send proof of Adminstration and their schedule.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not having administractor present during working hours which poses an immediate Health, Safety or personal rights risk to persons in care.
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The POC is due by 09/09/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 2 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 02:26 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
HSC
1569.153(d)

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1569.153(d)Theft and loss program; standards, property inventories and surrender of personal effects; secured areas(d) A written resident personal property inventory..This requirement is not met as evidenced by:
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The licensee has agreed to provide written inventory for all resident. The licensee has agreed to send proof of written inventory for residents.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not having residents' written inventory which poses a potential health, safety or personal rights risk to persons in care.
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POC due date by 9/21/2023
Type B
09/21/2023
Section Cited
CCR87462

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87462 Social Factors
The facility shall obtain sufficient information about each person's likes and dislikes and interests and activities..suggest the program of activities in which the individual may wish to participate. This requirement is not met as evidence by:
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The licensee has agreed to provide written document of residents dislikes and likes and provide activites calendar. Licensee has agreed to send proof to LPA.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not obtaining information dislikes and likes activites which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/21/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 3 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 02:58 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
HSC
1569.267(d)

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1569.267(d) Resident's Bill of Rights
(d)The licensee shall provide initial and ongoing training for all members of its staff to ensure that residents’ rights are fully respected and implemented. This requirement is not met as evidenced by:
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The licensee has agreed to provide training for staff. The licensee has agreed to send proof of staff training.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/21/2023
Type B
09/21/2023
Section Cited
HSC1569.158(g)(2)

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1569.158(g)(2) Family councils
(1) If a facility has a family council, the facility shall include.. members.. (2) If a facility does not have a family council, the facility shall provide, upon admission of a new resident, written representative of their right to form a family council.
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LIcensee has agreed to provide documents and send copies to LPA
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/21/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 4 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 03:24 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
HSC
1569.618(c)(3)

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1569.618(c)(3) Administration and management of residential care facilities; substituted qualifications; employee scheduling (c) The facility shall employ..:(3) Ensure that at least one staff member who has (CPR)on the premises at all times..This requirement is not met as evidenced by:
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The licensee has agreed to have at least one staff member on premises at all times who is certified CPR.The licensee has agreed to send proof of staff schedule and proof of valid certificate
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Based on observation, interview and reecord review the licensee did not comply with the section cited above by not having at least one staff member on premises at all times who is certified CPR.
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POC due date 9/9/2023
Type A
09/09/2023
Section Cited
CCR87413(a)(1)

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87413(a)(1) Personnel - Operations
(a) In each facility:
(1) When regular staff members are absent, there shall be coverage by personnel with qualifications adequate to perform the assigned tasks.This requirement is not met as evidenced by:
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The licensee has agreed to provide an updated LIC 500 and provide the following documents of which staff members provide coverage while others go back to their country.
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Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing staff coverage when regular staff return from their country
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POC due date 9/9/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 5 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 03:57 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/14/2023
Section Cited
CCR
87470(c)

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87470(c) Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.This requirement is not met as evidenced by
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The licensee has agreed to develop Infection Control Plan. Licensee has agreed to send LPA facility Infection Control Plan.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by creating An Infection Control Plan which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/14/2023
Type B
09/14/2023
Section Cited
CCR87208(a)

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87208(a)Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing.. the license application..This requirement is not met as evidenced by:
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The licensee has agreed to have a copy of facility Plan of Operation. Licensee has agreed to send LPA proof of evidence.
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Based on observation and interview the licensee did not comply with the section cited above evidenced by not providing a copy of facility Plan Of Operation which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/14/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 6 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/07/2023 at 04:33 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
87411(d)

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87411(d) Personnel Requirements - General
(d)All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69.. This requirement is not met as evidenced by:
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Licensee has agreed to send LPA proof of staff annual trainings
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Based on observation, interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/21/2023
Type B
09/21/2023
Section Cited
CCR87707(1)

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87707(1) Training Requirements If Advertising Dementia Special Care, Programming And/Or Environments
(1) Direct care staff shall complete six hours of orientation specific to the care of ..This requirement is not met as evidenced by:
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Licensee has agreed to send LPA proof of staff dementia training annual trainings
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Based on observation,interview and record review the licensee did not comply with the section cited above evidenced by not providing dementia training and initial training which poses a potential health, safety or personal rights risk to persons in care.
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POC due date 9/21/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 7 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/08/2023 at 07:52 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
1569.69(3)

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1569.69 (3) Employees assisting residents with self-administration of medication; training requirements
(3) An employee shall be required for hands-on shadowing training. resident in the self-administration of medications... This requirement is not met as evidenced:
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Licensee has agreed medication training for staff. Licensee agreed to send LPA proof of staff training
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Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having medication training for staff, which poses a potential health and safety risk to persons in care
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POC due date by 9/9/2023
Type A
09/09/2023
Section Cited
CCR87458(a)

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87458(a) Medical Assessment
(a)Prior to a person's acceptance as a resident, .. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.This requirement is not met as evidenced:
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Licensee has agreed to send LPA Physician's Report for three(3) residents
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Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3)physician reports, which poses a potiential health and safety risk to persons in care
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POC due date by 9/9/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 8 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/08/2023 at 10:35 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
87411(g)(1)

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87411 Personnel Requirements...(g)prior to employment or initial presence in the facility, all employees and volunteers...shall:(1) Obtain a California clearance...as required by law..This requirement is not met as evidenced by:
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Staff (S3) immediately left facility. Licensee/Administrator will submit a written statement of understanding of the regulation cited by
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The Licensee did not obtain a criminal record clearance for Staff #3 (S3) prior to S3 beginning employment or initial presence in the facility. Which poses an immediate health and safety risk to residents in care.
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POC due date 09/09/2023
Type A
09/09/2023
Section Cited
CCR87465(h)(2)

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87465(h)(2)Incidental Medical and Dental Care(h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in centrally stored medication.This requirement is not met as evidenced by:
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Licensee stated they will review the cited regulation, and will provide training for staff. Licensee has agreed to send proof to LPA.
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Based on observation, interview and record review the licnesee did not comply with the section cited above by having the centrally stored medication cabinet accessible to residents which poses an immediate Health, Safety or personal rights risk to persons in care.
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POC due date 09/09/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 9 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/08/2023 at 11:26 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
87507(a)

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87507(a) Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. This requirement is not met as evidenced by:
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Licensee has agreed to have documnets readily available to facility staff and to licensing agency staff. Licnesee has agreed to send proof to LPA.
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Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having one(1) admission agreements, which poses a potiential health and safety risk to persons in care
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POC due date 9/21/2023
Type B
09/21/2023
Section Cited
CCR87506(b)(15)

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87506(b)(15)Resident Records
(b) Each resident’s record shall contain at least the following information:(15)The.. Admission Agreements and 87457, Pre-admission Appraisal... This requirement is not met as evidenced by:
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Licensee has agreed to send LPA the three(3)misssing and have their forms at the facility.
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Based on observation,interview and recrod review the licensee did not comply with the section cited above by not having three(3) admission agreements, which poses a potiential health and safety risk to persons in care
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POC due date 9/21/2023
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


LIC809 (FAS) - (06/04)
Page: 10 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/08/2023 at 11:57 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: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/21/2023
Section Cited
CCR
87303(a)

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87303(a) Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times... the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
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Licensee has agree to send a LPA reciept and photo of bathroom cabin repaired.
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Based on observation and interview the licensee did not comply with the section cited above by having bathroom cabin broken and not in good repair which poses a potential health, safety or personal rights risk to persons in care.
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POC due date by 9/21/2023

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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


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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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 09/08/2023
NARRATIVE
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Record Review: During record review, Facility did not have three(3) Physician Reports, one (1) admissions Agreement and three (3) pre-admission appraisal. In addition, one (1) LIC621 and five (5) need/services plans missing. No activities are planned and no activities calendar available for residents. Facility did not obtain sufficient information of resident’s dislikes and likes for activities. Licensee failed to develop Infection Control Plan and have a written copy for staff. Furthermore, Licensee did not have Plan of Operation at the facility.

During staff record review, Licensee failed to provide the following training for staff: Resident's Bill of Rights, Administration of Medications, Daily Living, and Dementia Special Care. LPA discovered S1 and S2 are not CPR /t1st aid certificate. During today’s visit, Licensee did not have at least one certified CPR staff on premises. LPA discovered S3 did not have a criminal record clearance. which poses an immediate Health, Safety or personal rights risk to persons in

Based on observations today, a civil penalty in the amount of $500 dollars will be issued for no criminal record clearance. The facility will be issued nine (9) type A deficiencies and eleven (11) type B deficiency per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report (LIC809) was discussed and provided to staff Sonia Guevara, along with a copy of LIC809D, LIC421BG, and the appeal rights.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2023
LIC809 (FAS) - (06/04)
Page: 12 of 13
Document Has Been Signed on 09/08/2023 03:10 PM - It Cannot Be Edited


Created By: Mary Rico On 09/08/2023 at 02:07 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/09/2023
Section Cited
CCR
87411(d)(3)

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Personnel Requirements - General (d) All personnel shall be given on the job training.. (3) Skill and knowledge required to provide necessary resident care and supervision, including the ability to communicate with residents. This requirement is not met as evidenced by:
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Licensee stated they train and hire staff who can communicate with residents. Licensee has agreed to send proof to LPA of staff schedule.
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Based on obeservation,interview and record review, the licensee did not comply with the section cited above by not having staff being able to adequately communicate with residents due to lanaguage barrier which poses an immediate Health, Safety or personal rights risk to persons in
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POC due date 9/9/2023

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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:Efren Malagon
LICENSING EVALUATOR NAME:Mary Rico
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2023


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