361880543-2-19-2026-56-AS-BSIH-DRG3A8-20260219170417

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 01/21/2026
Date Signed: 02/19/2026 05:05:43 PM

Document Has Been Signed on 02/19/2026 05:05 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	GREEN MERRYLANDS		FACILITY NUMBER:	361880543
ADMINISTRATOR/ DIRECTOR:	BRANDON MARQUEZ-GUTIERREZ		FACILITY TYPE:	740
ADDRESS:	15986 BALTRAY WAY		TELEPHONE:	(909) 371-3402
CITY:	FONTANA	STATE: CA	ZIP CODE:	92336
CAPACITY: 6		CENSUS: 3	DATE:	01/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Facility-Staff/care giver Titus Irangus		TIME VISIT/ INSPECTION COMPLETED:	02:40 PM

NARRATIVE

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On 01/21/2026, Licensing Program Analysts (LPAs) Beena Singh and Paola Guerrero made an unannounced visit to the facility. The purpose of the visit was to conduct a required comprehensive annual inspection. LPAs met with staff/care giver Titus Irangus and was granted entry to the facility. At the time of the visit there were one (1) staff present, and three (3) residents present. LPA Singh explained the purpose of the visit to staff/care giver Titus Irangus.

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 four (4) residents. LPA was accompanied by staff/care giver Titus Irangus 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 observed no obstructions to indoor passageways. The facility is maintained at a comfortable temperature of 76 degrees Fahrenheit. LPAs inspected resident bedrooms; they are equipped with required furniture such as: mattresses, and storage space, lamps and chairs and sufficient lighting in the bedrooms. During the walk through, LPAs observed kitchen cabinet to be in despair. In addition, LPAs also observed no working lights in the laundry room. While inspecting facility garage LPAs observed a leakage coming from the water filter LPAs observed mold on the wall due to the leakage. LPAs will issue deficiency. Moreover, LPAs observed that bathrooms were clean, and appliances were operating appropriately. LPAs observed grab bars and non-skid mat in the resident bathrooms.

***Continuation in LIC809C ***

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS	FACILITY NUMBER: 361880543
	VISIT DATE: 01/21/2026

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LPAs observed night-lights maintained in hallways and passages to non private bathrooms. LPsA observed the outdoor passageways free of obstructions. LPAs observed sufficient furniture and lighting throughout the facility. LPAs measured and observed the water temperature in the bathroom to be at 110 degrees Fahrenheit. The facility is equipped and working 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.

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: LPAs observed one staff sufficient number of staff to provide care and supervision to the residents in care.

LPAs observed Emergency supplies in one of the cabinets. LPA observed first aid kit and first aid manual at the facility.

Record Review: LPAs reviewed three (3) resident files for admission agreements, updated physician reports, and needs and services plans. LPAs reviewed two (2) staff files for First Aid/CPR certification, criminal record clearance, training, and health screenings with tuberculosis (TB) test results. LPAs observed on-the-job training provided and documented Residential Care for the Elderly (RCFE) and Dementia, Postural Supports, Hospice Care training. LPAs observed no issues. LPAs audited Medication administration Record system (MARS) matched with medication administrated to the residents. LPAs observed there were activity program for the residents at the facility.Fire drill conducted on 12/1/2025.Liability Insurance valid through 03/28/2025 to 03/28/2026.License fee is current 1/21/2026.

Deficiencies were cited during today's visit. An exit interview was conducted where this report, LIC809, LIC809C, 809D and Appeal Rights were discussed and provided via email to Licensee-Sandy Zhao due to technical issues during this visit..

NAME OF LICENSING PROGRAM MANAGER: Efren Malagon
NAME OF LICENSING PROGRAM ANALYST: Beena Singh
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 01/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/19/2026 05:05 PM - It Cannot Be Edited

Created By: Beena Singh On 01/21/2026 at 02:02 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
RIVERSIDE, CA 92507

FACILITY NAME: GREEN MERRYLANDS	FACILITY NUMBER: 361880543
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 01/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation the licensee did not comply with the section cited above maintenance and operation, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 01/22/2026
	Plan of Correction
1 2 3 4	Licensee will ensure facility is clean,sanitary and in good repair for residents in care by repairing the sink cabinet, lights in laundry room, water filter leakage in garage-mold on the wall, by POC due date and evidence/invoice to be sent to LPA Singh via email by the Plan of Correction(POC) due date 1/21/2026.

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.

	Efren Malagon
NAME OF LICENSING PROGRAM MANAGER:

	Beena Singh
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 01/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2026

LIC809 (FAS) - (06/04)

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