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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 12:28:41 PM

Document Has Been Signed on 02/29/2024 12:28 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
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:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Staff Jonathan Israel Guzman PinedaTIME COMPLETED:
12:40 PM
NARRATIVE
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On 02/29/2024 at 09:40 AM, Licensing Program Analyst (LPA) Melody Brown, met with Staff Jonathan Israel Guzman Pineda to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

Per documents review during the facility visit today, 02/29/2024, LPA Brown reviewed documents and interview staffs and observed that Staff #5 (S5) had been working at the facility since 02/20/2024 and per documents review, LPA Brown observed that S5 does not have criminal background clearance and S5 reported to LPA Brown that S5 started working at the facility on 02/20/2024. LPA Brown informed Licensee Zhao that deficiency will be issued and Civil Penalties were assessed during the facility visit today, 02/29/2024 with the amount of $1000.00 will be assessed for allowing S5 to work at the facility without criminal background clearance and will continue to be assessed of $100.00 per day per citation until corrected.

Also, during today's visit, LPA Brown observed no Administrator present at the facility. S5 reported to LPA Brown that the facility's Administrator's out for vacation then later informed LPA Brown that Administrator was out for family emergency. Deficiency will be issued.

Per records review, the facility were cited for the same regulations within 12-month period and this would be the third offense for HSC 1569.618(a) and CCR 87355(e)(1), an immediate civil penalty will be issued today, 02/29/2024 with the amount of $1000.00 for third offense repeat violation within 12-month period for not having administrator present at the facility during working hours and $1000.00 for staff working at the facility without criminal background clearance, third offense.

An exit interview was conducted where this report, LIC809, LIC809D, 421BG, 421FC, LIC421IM and Appeal Rights were discussed and provided to staff Jonathan Israel Guzman Pineda.
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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Document Has Been Signed on 02/29/2024 12:28 PM - It Cannot Be Edited


Created By: Melody Brown On 02/29/2024 at 11:33 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/08/2024
Section Cited
HSC
1569.618

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HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
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Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit 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 having an Administrator present during working hours at the facility which pose potential 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: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/29/2024 12:28 PM - It Cannot Be Edited


Created By: Melody Brown On 02/29/2024 at 11:50 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/01/2024
Section Cited
CCR
87355(e)(1)

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87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by:
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Licensee stated to not allow S5 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.
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Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #5 (S5) criminal record clearance before allowing S5 to work at the facility on 02/20/2024 which pose immediate health, safety and 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: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024


LIC809 (FAS) - (06/04)
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