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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 07/24/2024
Date Signed: 07/24/2024 09:43:59 AM

Document Has Been Signed on 07/24/2024 09:43 AM - 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/
DIRECTOR:		BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 5DATE:
07/24/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Administrator Brandon Marquez TIME VISIT/
INSPECTION COMPLETED:
09:45 AM
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On 07/24/2024 at 09:00 AM, Licensing Program Analyst (LPA) Melody Brown made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPA Brown met with Administrator Brandon Marquez and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present.

During the visit, Administrator Brandon Marquez reported to LPA Brown that there are two (2) residents that tested positive for Covid-19 and are isolated. Also, one (1) resident who's out with family for the weekend tested positive as well for Covid-19. Therefore, total of three (3) resident tested positive for Covid-19 at the facility. LPA Brown informed Administrator Brandon Marquez that the required comprehensive annual inspection will be completed in a later time.

An Exit interview was conducted where this report, LIC809 was discussed and provided to Administrator Brandon Marquez.

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/24/2024
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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