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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 08/07/2024
Date Signed: 08/07/2024 05:23:17 PM

Document Has Been Signed on 08/07/2024 05:23 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/
DIRECTOR:		BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 6CENSUS: 5DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:45 AM
MET WITH: Vicente Picache ArambulaTIME VISIT/
INSPECTION COMPLETED:
05:30 PM
NARRATIVE
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On 08/07/2024 at 08:45 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 a staff and was granted entry to the facility. At the time of the visit there were two (2) staff present, and five (5) residents present. Vicente Picache Arambula reported to LPA Brown that Administrator Brandon Marquez was not at the facility. LPA Brown contacted Administrator Marquez and informed of the visit but call was not answered. LPA Brown explained the purpose of the visit to Vicente Picache Arambula.

The facility is a five (5) bedroom, two (2) bathroom home with a kitchen/dining area, living room, laundry area and garage. The facility is Residential Care Facility for the Elderly (RCFE). The facility is licensed for a capacity of six (6) residents of which six (6) can be non-ambulatory residents. The facility has two (2) Hospice Waiver. The current census is five (5) residents. LPA Brown was accompanied by Vicente Picache Arambula to conduct a general overall inspection, which included, but was not limited to, the following:


Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPA Brown observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPA Brown inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space. However, LPA Brown did not observed lamps and chairs. Technical Violation issued. Also, LPA Brown observed sufficient lightning. Moreover, LPA Brown observed that bathrooms were clean, and appliances were operating appropriately. LPA Brown observed grab bars and non-skid mat in the resident bathrooms. Furthermore, during the tour of the facility, LPA Brown was denied access of the Administrator Office for spot inspection. Deficiency will be issued. LPA Brown observed movable bins used for storage of solid wastes outside the facility in disrepair. Deficiency will be issued.LPA Brown observed movable bins used for storing or transporting solid wastes from the premises does not have cover inside the facility. Deficiency will be issued. LPA Brown observed no chair and lamp on all resident bedrooms. Technical Violation will be issued. ***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 61
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: 08/07/2024
NARRATIVE
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Incomplete Emergency Kit observed at the facility. Deficiency will be issued. LPA Brown observed no first aid manual approved by the American Red Cross, The American Medical Association or a state or federal health agency. Deficiency will be issued.
Record Review: LPA reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPA Brown observed that Resident #2 (R2) and Resident #3 (R3) Admission Agreement do not have facility representative signature. Deficiency will be issued. LPA reviewed three (3) staff files for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test results. LPA Brown observed that no on-the-job training provided for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4), also, no documented Residential Care for the Elderly (RCFE) and Dementia, Postural Supports, Hospice Care trainings for S3 and S4. Deficiencies will be issued.

During medication audit, LPA Brown observed that one (1) of R3's medication was given to R3 but per Medication Administration Records (MAR) review, it does not show that R3's medication was given per physician's direction. Also, LPA Brown observed one (1) of R3's medication was not given to R3 due to no refill available at the facility since 08/03/2024, two (2) of R3's medication were not given to R3 due to no refill at the facility since 08/04/2024 and one (1) medication was not given to R3 due to no refill at the facility since 08/06/2024. Deficiency will be issued.



LPA Brown observed no activity program for the residents at the facility. Defiency will be issued.

In addition, LPA Brown observed that no Administrator present at the facility during working hours as required and LPA Brown contacted Administrator Marquez and Licensee Zhao. Deficiency will be issued. Deficiency will be issued.

Per records review, the facility were cited for the same regulations within 12-month period for CCR 87309(a)(1) and 87608(a)(5)(B) civil penalty will be issued today, 08/07/2024 with the amount of $250.00 per repeat violation. Also, the facility will be issued immediate civil penalty for repeat violation of $1000.00 for HSC Section 1569.618(a) for third offense within 12-month period.

An exit interview was conducted where this report, LIC809, LIC809D, LIC421FC, LIC421IM, LIC9102TV, LIC9102, and Appeal Rights were discussed and provided to Vicente Picache Arambula.

***This is an amended copy of LIC809C issued on 08/07/2024***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 61 of 61
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: 08/07/2024
NARRATIVE
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LPA Brown observed no nightlight maintained in hallways and passages to nonprivate bathrooms. Deficiency will be issued. LPA Brown observed the outdoor passageways not free of obstructions. Deficiency will be issued. To add to that, LPA Brown observed Resident #1 (R1) with full bed rails and Vicente Picache Arambula reported to LPA Brown that R1 is not on Hospice Care and per records review, no written order from R1's physician was observed indicating the need for postural support/full bed rail. Also, LPA Brown observed,no exception letter submitted and approved by Community Care Licensing Division (CCLD) for R1's full bed rail. Deficiency will be issued. To add to that, LPA Brown observed Resident #2 (R2), Resident #3 (R3), and Resident #4 (R4) have half bed rails. Vicente Picache Arambula reported to LPA Brown that R2, R3, and R4 don’t have written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued. Moreover, during the tour of the facility, LPA Brown observed one (1) screw driver, two gallons of laundry detergent in the laundry area not locked and accessible to resident in care. Deficiency will be issued. LPA Brown observed sufficient furniture and lighting throughout the facility. LPA Brown measured and observed the water temperature in the bathroom to be at 116 degrees Fahrenheit. The facility is equipped with operating smoke detectors and carbon monoxide alarms. Posters such as personal rights, the CCLD complaint poster, Ombudsman Poster and the Emergency Disaster plan were posted in a common area.

Furthermore, during the tour of the facility, LPA Brown observed broken screens, metal wires, carpets, boxes in an unlocked kitchen drawer, accessible to residents in care. Deficiency will be issued. There was a designated storage space for resident/staff files. There is a cabinet with the resident’s medications locked in the medication cabinet.

Food Service: Seven (7) days non-perishable and three (3) days perishable food supply observed at the facility.

Care & Supervision: The facility does not have an administrator present in the facility. LPA Brown observed no sufficient number of staff to provide care and supervision to the residents in care as no staff scheduled to work at night as required for facility with dementia residents. Deficiency will be issued.

***Continuation in LIC809C ***

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 61
Document Has Been Signed on 08/08/2024 10:29 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 08/08/2024 07:27 AM


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)(1)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
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Based on observation, interview and record review, the licensee did not comply with the section cited above
by not ensuring that one (1) screwdriver and two (2) gallons of laundry detergent in the laundry room, are locked and not accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee stated to submit Signed Statement of Understanding on CCR 87309(a)(1) to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
HSC
1569.618(a)
Other Provisions
(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:
Deficient Practice Statement
1
2
3
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has an Administrator during normal working hours as required which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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2
3
4
Licensee stated to hire an additional administrator for the facility and submit Signed Statement of Understanding on HSC 1569.618(a) to LPA Brown on POC due date.
*** This is an amended copy of LIC809 issued on 08/07/2024 due to new form LIC421IM issued today w/ amount of $1000.00. Form LIC421FC with the amount of $250.00 issued on 08/07/2024 will be deleted.***
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87411(d)
Personnel Requirements - General
(d) All personnel shall be given on the job training or have related experience in the job assigned to them. This training and/or related experience shall provide knowledge of and skill in the following, as appropriate for the job assigned and as evidenced by safe and effective job performance:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not having the required on the job training and/or related experience in the job for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee stated to submit the required on the job training and/or related experience in the job for Staff #2 (S2), Staff #3 (S3) and Staff #4 (S4) to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 4 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(1)
Other Provisions
(1) The department shall adopt regulations to require staff members of residential care facilities for the elderly who assist residents with personal activities of daily living to receive appropriate training. This training shall consist of 40 hours of training. A staff member shall complete 20 hours, including six hours specific to dementia care, as required by subdivision (a) of Section 1569.626 and four hours specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696, before working independently with residents. The remaining 20 hours shall include six hours specific to dementia care and shall be completed within the first four weeks of employment. The training coursework may utilize various methods of instruction, including, but not limited to, lectures, instructional videos, and interactive online courses. The additional 16 hours shall be hands-on training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) complete the required Residential Care for the Elderly (RCFE) 40 hours of training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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2
3
4
Licensee stated to submit S3 and S4 enrollment on the required RCFE 40 hours of training to LPA Brown on POC due date.

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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 5 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) completed the required dementia training annually which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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2
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Licensee stated to submit Signed Statement of Understanding on HSC1569.625(b)(2) and submit to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
HSC
1569.626(a)
Other Provisions
(a) All residential care facilities for the elderly shall meet the following training requirements, as described in Section 1569.625, for all direct care staff:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 (S3) and Staff #4 (S4) at the facility completed the required dementia training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of enrollment of all staff on the required dementia training to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 6 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that Staff #3 and Staff #4 completed the required postural supports, restricted conditions or health services, and hospice care training which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to submit proof of S3 and S4 training enrollment on postural supports, restricted conditions or health services, and hospice care to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(a)(8)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the facility has a complete supply of first aid kit which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase first aid kit and submit proof to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 7 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(8)(A)
Incidental Medical and Dental Care Services
(8) If a facility has no medical unit on the grounds, a complete first aid kit shall be maintained and be readily available in a specific location in the facility. The kit shall be a general type approved by the American Red Cross, or shall contain at least the following: (A) A current edition of a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the facility has a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase a first aid manual approved by the American Red Cross, the American Medical Association or a state or federal health agency and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #3 (R3) medications were given per R3 physicians's order as evidenced of one (1) of R3's medication was given to R3 but per Medication Administration Records (MAR) review, it does not show that R3's medication was given per physician's direction. Also, LPA Brown observed one (1) of R3's medication was not given to R3 due to no refill available at the facility since 08/03/2024, two (2) of R3's medication were not given to R3 due to no refill at the facility since 08/04/2024 and one (1) medication was not given to R3 due to no refill at the facility since 08/06/2024. This incidents poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on CCR 87465(c)(2) and submit proof to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 8 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #1 (R1) to have full bed rail but per records review, R1 is not on hospice and exception report submitted to licensing for approval for full bed rail which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee removed R1's full bed rail during the visit. Plan of Correction (POC) cleared.
Type A
Section Cited
CCR
87705(c)(4)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs as identified in his/her current appraisal. (A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's a staff scheduled to work the night shift, awake and on duty as required for facility with dementia residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
1
2
3
4
Licensee stated to schedule a staff to work the night shift and submit an uodated Personnel Report/Staff Schedule to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 9 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not developing the required Infection Control Plan for the Facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to submit the required Infection Control Plan to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
HSC
1569.32
Regulations
Any duly authorized officer, employee, or agent of the department may, upon presentation of proper identification, enter and inspect any place providing personal care, supervision, and services at any time, with or without advance notice, to secure compliance with, or to prevent a violation of, this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by denying LPA Brown access to the Administrator Office during the facility Inspection which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to train all staff on HSC 1569.32 and submit proof to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 10 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(f)(3)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (3) All containers, except movable bins, used for storage of solid wastes shall have tight-fitting covers on the containers; shall be in good repair; shall have external handles; and shall be leakproof and rodent-proof.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview, record review, the licensee did not comply with the section cited above by not ensuring that the container used for storage of solid waste is in good repair which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to replaced the broken container used for storage of solid waste and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87303(f)(4)
Maintenance and Operation
(f) Solid waste shall be stored and disposed of as follows: (4) Movable bins when used for storing or transporting solid wastes from the premises shall have tight-fitting covers on the containers; shall be in good repair; and shall be rodent-proof unless stored in a room or screened enclosure.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that teh movable bin used for storing solid wastes does not have cover which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to purchase movable bins used for storing or transporting solid wastes with cover and submit proof to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 11 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87307(d)(5)
Personal Accommodations and Services
(5) Night lights shall be maintained in hallways and passages to nonprivate bathrooms.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that nightlights are maintained in hallways and passages to nonprivate bathrooms which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to obtain/purchase nightlights in hallways and passages to nonprivate bathrooms and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87307(d)(6)
Personal Accommodations and Services
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that the outdoor passageway is kept free of obstruction which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to pull out the broken screen windows, metal wires, boxes, carpets that blocks the outdoor passageway and submit proof to LPA Brown on POC due date.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 12 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(c)
Admission Agreements
(c) Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident's representative, if any, and the licensee or the licensee's designated representative no later than seven days following admission. Attachments to the agreement may be utilized as long as they are also signed and dated as prescribed above.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that Resident #2 (R2) and Resident #3 (R3) Admission Agreement were signed by the facility representative
which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
LIcensee stated to sign R2 and R3 Admission Agreement and submit proof to LPA Brown on Plan of Correction (POC) due date.
Type B
Section Cited
CCR
87608(a)(5)(A)
Postural Supports
(A) A bed rail that extends from the head half the length of the bed and used only for assistance with mobility shall be allowed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by allowing Resident #2 (R2), Resident #3 (R3) and Resident #4 (R4) to have half bed rail and not ensuring that they have written order from their physician indicating the need for half bed rail for mobilitywhich poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee removed R2, R3 and R4 half bed rail during the visit. POC cleared.
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 13 of 61
Document Has Been Signed on 08/07/2024 05:23 PM - It Cannot Be Edited


Created By: Melody Brown On 08/07/2024 at 02:25 PM
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: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(7)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (7) An activity program shall address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that there's an activity program that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/16/2024
Plan of Correction
1
2
3
4
Licensee stated to submit an activity program that address the needs and limitations of residents with dementia and include large motor activities and perceptual and sensory stimulation to LPA Brown on Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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