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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 03/13/2024
Date Signed: 03/13/2024 01:56:50 PM

Document Has Been Signed on 03/13/2024 01:56 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:
03/13/2024
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Administrator Brandon MarquezTIME COMPLETED:
02:00 PM
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On 03/13/2024 at 11:45 AM, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility in order to verify clearance of plans of correction created with Licensee Sandy Zhao, from visit on 02/15/2024, 02/29/2024 and 03/06/2024. LPA Brown met with Administrator Brandon Marquez. 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 02/29/2024 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. Based on observation on 02/29/2024 and 03/06/2024, Licensee continued to allow S5 to work at the facility without criminal background clearance. The plan of correction was to obtain S5 Criminal Record Clearance. On 03/08/2024, Licensee Sandy Zhao submitted Staff #5 (S5) Criminal Record Clearance granted on 03/07/2024. LPA Brown provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 02/15/2024 for 87309 Storage Space (a)(1). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87309 Storage Space (a)(1). LPA Brown provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 02/15/2024 for 87506 Resident Records (e). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87506 Resident Records (e). LPA Brown provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 02/15/2024 for 87608 Postural Supports (a)(5)(B). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87608 Postural Support (a)(5)(B). LPA Brown provided a clearance letter for this deficiency during the visit. ***Continuation in LIC809C***


SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2024
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: 03/13/2024
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The Licensee was cited on 02/15/2024 for CCR 87224 Eviction Procedures (a). On 03/06/2024, Licensee Sandy Zhao submitted staff training on CCR 87224 Eviction Procedures (a). LPA Brown provided a clearance letter for this deficiency during the visit.

The Licensee was cited on 02/29/2024 for HSC 1569.618 (a). On 03/06/2024, Licensee Sandy Zhao submitted signed Statement of Understanding on HSC 1569.618 (a). LPA Brown provided a clearance letter for this deficiency during the visit.

An exit interview was conducted and this report, LIC809 was discussed and provided to Administrator Brandon Marquez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2024
LIC809 (FAS) - (06/04)
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