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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004801
Report Date: 09/20/2021
Date Signed: 09/20/2021 03:02:02 PM

Document Has Been Signed on 09/20/2021 03:02 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, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GREEN PINES HOME, INC.FACILITY NUMBER:
306004801
ADMINISTRATOR:MARTINEZ, SHELLYFACILITY TYPE:
735
ADDRESS:509 ADAMS AVETELEPHONE:
(714) 478-0695
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
09/20/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Administrators, Michael Martinez and Shelly MartinezTIME COMPLETED:
03:15 PM
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On this day Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and was granted entry into the facility by staff. LPA's temperature was checked upon arrival. LPA Tirre met with Administrator and explained the reason for the visit.
During the visit LPA toured the facility with Administrator, Facility is a 4 bedroom (3 Client rooms and 1 staff room) and 2 bathroom single story home. There are 6 Clients in care. LPA observed facility has required Department postings. LPA toured all clients rooms, all rooms where within regulations. All restrooms observed contained working water basin, soap, toilet paper, paper towels and hand sanitizer. Clients were observed relaxing in bedrooms and living room.

Facility has supplies of PPE. Facility has ample food supply. LPA observed facility has emergency food and water supply. Facility has evacuation plan posted on wall. LPA observed Administrator certificate expiring on 1/14/23. Facility has 1 fire extinguisher fully charged. Facility has a secured location for Client medication and files. Facility has 30 days supply of medications for clients. LPA reviewed Clients files during visit. Clients emergency contact information and physicians reports are current.

An exit interview was conducted with Administrator Shelly Martinez and copy of report was left at facility.
SUPERVISORS NAME: Alisa Ortiz
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2021
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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