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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 02/29/2024
Date Signed: 02/29/2024 12:23:22 PM

Document Has Been Signed on 02/29/2024 12:23 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:
02/29/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Staff Jonathan Israel Guzman PinedaTIME COMPLETED:
12:40 PM
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On 02/29/2024 at 09:40 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Administrator Brandon Marquez, from visit on 02/15/2024. LPA Brown met with staff Jonathan Israel Guzman Pineda. Licensee Sandy Zhao was contacted and informed of the visit.

The following Plan of Correction (POC)s were cleared at the time of the visit:
The licensee was cited on 02/15/2024 for 87465 (a)(6) Incidental Medical and Dental Care. During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was 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 on 02/16/2024. Therefore, the POC was not cleared until today's visit where Licensee Zhao submitted proof of staff Training to LPA Brown. Civil penalties will be assessed in the amount of $100 per day for thirteen (13) days. The LPA provided a clearance letter for this deficiency during the visit.

The following deficiency were not cleared during the time of the visit:



The Licensee was cited on 02/15/2024 for 87309 Storage Space (a)(1). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87309(a)(1). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for fourteen (14) days.

The Licensee was cited on 02/15/2024 for 87506 Resident Records (e). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87506(e). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for seven (7) days.

***Continuation on LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/29/2024
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: 02/29/2024
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The Licensee was cited on 02/15/2024 for 87608 Postural Supports (a)(5)(B). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not have staff training on site. Plan of Correction was to train all staff on CCR 87608(a)(5)(B). Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for seven (7) days.

The Licensee was cited on 02/15/2024 for 87224 Eviction Procedures (a). During today's visit and based on record review and interview, LPA Brown observed that the licensee did not submit a self-certification letter that the regulation has been read and is understood. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for seven (7) days.

Moreover, 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 02/29/2024 in form LIC809 - Deficiency as durimg today's visit, LPA Brown observed no Administrator present at the facility during working hours.

An exit interview was conducted with staff Jonathan Israel Guzman Pineda where this report, LIC809 along with Civil Penalty Assessment pages, and Appeal Rights were reviewed and provided.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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