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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880543
Report Date: 08/13/2025
Date Signed: 08/13/2025 02:20:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240213155615
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:
08/13/2025
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Alexia Portillo- CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff neglect resulted in resident sustaining stage three pressure ulcer.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Alexia Portillo and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Staff neglect resulted in resident sustaining stage three pressure ulcer. Regarding the allegation stated above LPA conducted a review of records pertaining to Resident #1 during the review of records LPA discovered that on 7/14/2023 Resident #1 was admitted to Green Merrylands, during further review LPA discovered that on R#1 Physicians Report under physical status R#1 did not have any indication or history of skin condition or skin breaks. In addition, during further review LPA discovered that on R#1 Pre-Appraisal information it lists that R#1 did not have skin breakdown, wound or sores noted, Pre-Appraisal only indicated that R#1 only had redness on bottom due to pressure. Furthermore, weekly skin check documentation indicated that R#1 did not have any skin breakdown, wounds, or sores. During review LPA discovered that on 9/18/2023 R#1 was relocated and admitted to a new facility.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 56-AS-20240213155615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 08/13/2025
NARRATIVE
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During review of record where R#1 was admitted demonstrated that R#1 arrived at the facility with pressure sores on legs and back. Local hospital listed Resident #1 pressure injury to be at a stage 3 injury appearance. Based on the evidence gathered during the investigation, the above allegation is Substantiated.

Substantiated A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. Title 22 regulations, Personnel Requirements – General 87411 (a), from division 6, chapter, article 6, is being cited on the attached LIC 9099 D.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided, along with a copy of the appeal rights to Facility Caregiver.

***In addition***


An immediate civil penalty is assessed for $500.00, per Health and Safety Code 1548 (c). In addition, an additional review is being conducted and additional civil penalty may be imposed per Health and Safety Code 1569.49 (f).

Exit interview conducted and copy of report provided to Facility Caregiver Alexia Portillo
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 56-AS-20240213155615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/13/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/14/2025
Section Cited
CCR
87411(a)
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Personnel Requirements – General.... (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.

This requirement was not met as evidenced by:
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The Licensee shall ensure that Personnel Requirements are met daily. Staff shall always ensure that residents are receiving care to meet their needs. If a resident need cannot be met, then a higher level of care may be needed. Hospice care shall not relieve staff of their duties. Proof of understanding shall be provided, and emailed to LPA by POC date 8/14/2025.
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 Facility staff failed to seek a higher level of care for R1’s pressure injurie[s] which multiplied while in care. The facility staff failed to inquire, assess the number, and seriousness of the pressure ulcers to determine if the level of care being provided to R1 was adequate, which poses an immediate Health, Safety, or Personal Rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/13/2024 and conducted by Evaluator Paola Guerrero
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240213155615

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:
08/13/2025
UNANNOUNCEDTIME BEGAN:
12:38 PM
MET WITH:Alexia Portillo- CaregiverTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident's records are not being provided to their representative.
Facility failed refund any prepaid fees to their representative.
Staff obstructed resident relocation by not permitting the removal of resident's belongings.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Paola Guerrero conducted an unannounced visit to deliver findings on the allegations listed above. LPA met with Facility Caregiver Alexia Portillo and explained the purpose of the visit. The investigation consisted of interviews, observations, and review of records.

First allegation: Resident's records are not being provided to their representative. Regarding the allegation stated above LPA conducted an interview with Staff #1 who informed LPA that residents records were provided to R#1 Responsible Party. LPA attempted to contact R#1 responsible party and was unsuccessful. LPA observed that other attempts to contact R#1 responsible party were made however, were also unsuccessful and calls were not returned. LPA requested documentation pertaining to R#1 LPA observed that facility had R#1 records on file.

Second allegation: Facility failed refund any prepaid fees to their representative. Regarding the allegation stated above LPA conducted an interview with staff #1 who informed LPA that the facility licensee was in communication with R#1 Responsible Party.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 56-AS-20240213155615
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 08/13/2025
NARRATIVE
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Staff #1 informed LPA that staff is unaware if refund was given to R#1 responsible party. LPA attempted to contact R#1 reporting party, however, was unsuccessful. LPA observed that other attempts to contact R#1 responsible party were made however, no calls were answered or returned.

Third allegation: Staff obstructed resident relocation by not permitting the removal of resident's belongings. Regarding the allegation stated above LPA conducted an interview with Staff #1 regarding the allegation S#1 informed LPA that belongings were not withheld and were given to R#1 responsible party. In addition, Staff #1 informed LPA that Resident #1 responsible party had arrived with Law Enforcement to the facility and not because the facility was refusing to release R#1 personal belongings. LPA attempted to contact Resident #1 reporting party however, calls were not answered or returned. Based on lack of evidence obtained during the course of the investigation, LPA has determined that the above allegations are Unsubstantiated.

Unsubstantiated: meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where this report (LIC 9099) was discussed, and a copy was provided to Facility Caregiver Alexia Portillo at the end of the visit.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Paola Guerrero
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5