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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 02/15/2024
Date Signed: 02/15/2024 12:03:49 PM

Document Has Been Signed on 02/15/2024 12:03 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, 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:
02/15/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:08 AM
MET WITH:Administrator Brandon Marquez TIME COMPLETED:
12:08 PM
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On 02/15/2024, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee, Sandy Zhao from visit on 01/22/2024. LPA Brown met with staff .

The following Plan of Correction (POC)s were not cleared at the time of the visit:
The Licensee was cited on 01/22/20224 for 87224 Eviction Procedures (a). Based on observation and interview, the Licensee refused to accept R1 back to the facility upon hospital discharge. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024.

The Licensee was cited on 01/22/2024 for 87465 Incidental Medical and Dental Care (a)(6). Based on observation, interviews and records review, Licensee did not update R3, R4 and R5 Medication Administration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order. Licensee did not submit the required plan of correction on the due date on 01/23/2024. Deficiency will be issued with new due date during this visit on 02/15/2024.

The Licensee was cited on 01/22/2024 for 87309 Storage Space (a)(1). Based on observation, interview and records review, LIcensee did not lock the one (1) knife at the kitchen cabinet making it accessible to residents in care. Licensee did not submit the required plan of correction on the due date on 01/23/2024. Deficiency will be issued with new due date during this visit on 02/15/2024.

The Licensee was cited on 01/22/2024 for 87303 Maintenance and Operation (a). Based on observation and interview, Licensee did not have the kitchen cabinet and laundry cabinet in good repair. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024. *** Continuation on LIC809C ***
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/15/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 02/15/2024
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The Licensee was cited on 01/22/2024 for HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) Based on observation, interview and records review, the Licensee did not have Administrator present during working hours at the facility. Licensee did not submit the required plan of correction on the due date on 01/29/2024. Deficiency will be issued with new due date during this visit on 02/15/2024.

An exit interview was conducted where this report was discussed and provided to Administrator Brandon Marquez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 02/15/2024 12:03 PM - It Cannot Be Edited


Created By: Melody Brown On 02/15/2024 at 11:31 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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2024
Section Cited
CCR
87465(a)(6)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.
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Type A
02/16/2024
Section Cited
CCR87309(a)(1)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
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Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.
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Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.
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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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 02/15/2024 12:03 PM - It Cannot Be Edited


Created By: Melody Brown On 02/15/2024 at 11:39 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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87506(e)

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87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.
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Type B
02/23/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:
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Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date.
Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.
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Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.
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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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 02/15/2024 12:03 PM - It Cannot Be Edited


Created By: Melody Brown On 02/15/2024 at 11:43 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
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2024
Section Cited
CCR
87224(a)

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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by:
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Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.
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Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.
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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:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 02/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/15/2024


LIC809 (FAS) - (06/04)
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