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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 08/08/2024
Date Signed: 08/08/2024 10:34:14 AM

Document Has Been Signed on 08/08/2024 10:34 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:
08/08/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Vicente Picache ArambulaTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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On 08/08/2024 at 10:00AM, Licensing Program Analysts (LPAs) Melody Brown and Becky Mann met with Vicente PIcache Arambula to initiate a Case Management and issue additional Civil Penalty for the Annual Comprehensive Inspection conducted on 08/07/2024.

Per records review, the facility were cited for the same regulations within 12-month period for California Code of Regulation (CCR) 87411(d), CCR 87470(c), civil penalty will be issued today, 08/08/2024 with the amount of $250.00 per repeat violation within 12 -month period.

In addition, LPAs Brown and Mann amended the report issued on 08/07/2024 and issued new form Immediate Civil Penalty - Repeat Violation (LIC421IM) with the amount of $1,000.00 for HSC Section 1569.618(a), third offense within 12-month period.

An exit an interview was conducted, where this report, LIC809, amended copy of LIC809C and LIC809D LIC421FC, LIC421IM and Appeal Rights were discussed and provided to Vicente Picache Arambula.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 08/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/08/2024
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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