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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 03/06/2024
Date Signed: 03/06/2024 01:55:08 PM

Document Has Been Signed on 03/06/2024 01:55 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:
03/06/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Jonathan Israel Guzman PinedaTIME COMPLETED:
02:15 PM
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On 03/06/2024 at 12:45 PM, Licensing Program Analysts (LPAs) Melody Brown and Paola Guerrero conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee Sandy Zhao, from visit on 02/15/2024 and 02/29/2024. LPA Brown met with staff Jonathan Israel Guzman Pineda. Licensee Sandy Zhao was contacted and informed of the visit.

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

The Licensee was cited on 02/29/2024 for 87355(e)(1) Criminal Record Clearance for allowing Staff #5 to work at the facility without criminal background clearance. Licensee continued to allow S5 to work at the facility without criminal background clearance. Therefore Plan of Correction (POC) was not cleared at the time of the visit. Civil penalty will be assessed in the amount of $100 per day for six (6) days.

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, LPAs Brown and Guerrero 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 penalty will be assessed in the amount of $100 per day for six (6) 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, LPAs Brown and Guerrero 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 penalty will be assessed in the amount of $100 per day for six (6) days.

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, LPAs Brown and Guerrero 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 penalty will be assessed in the amount of $100 per day for six (6) days.


***Continuation on LIC809C ***



SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/06/2024
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 2
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: 03/06/2024
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The Licensee was cited on 02/15/2024 for 87224 Eviction Procedures (a). During today's visit and based on record review and interview, LPAs Brown and Guerrero 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 penalty will be assessed in the amount of $100 per day for six (6) days.

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: 03/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2024
LIC809 (FAS) - (06/04)
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