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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004801
Report Date: 08/31/2023
Date Signed: 08/31/2023 10:46:57 AM

Document Has Been Signed on 08/31/2023 10:46 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, 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: 5DATE:
08/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Frank Pascua
Shelly Martinez3		TIME COMPLETED:
11:00 AM
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On this day, Licensing Program Analysts (LPAs) Claudia Gutierrez and Dwayne Mason conducted an unannounced visit for the purpose of conducting a required annual visit. LPAs were greeted and granted entry into the facility by Staff Frank Pascual and explained the reason for the visit. Administrator (AD) Shelly Martinez at 9 a.m.

During the visit, LPAs toured the facility. Facility is a single-story home and consists of three client rooms, one staff room and two bathrooms. Facility currently has five clients in care. During time of visit clients were not present, as they had gone to day program for the day. All client bedrooms had the required furnishings. LPAs observed all client beds had linens and blankets. The back yard has a shaded sitting area. Bathrooms were observed to be free of debris and mildew, faucets and toilets were operational. Water temperature tested at 111.0 F degrees.

LPAs observed emergency disaster plan with means of exiting and emergency phone numbers listed and posted in the living area and entrance way of the facility. Food menu was also posted and visible. LPAs observed the facility has a 2-day supply of perishables and a 7-day supply of non-perishable food as required by regulations. Smoke detectors and carbon monoxide detectors tested operational. Fire extinguisher was observed to be mounted and fully charged. Stove burners, microwave, washer, and dryer were all inspected. Sharps were observed locked in a kitchen drawer. All and any toxic chemicals, cleaning solutions, laundry toxins and disinfectants are inaccessible to clients. Medication cabinet was observed to be locked and lock is operational. Disaster drills are conducted monthly at the facility and last drill was conducted on 8/16/23. LPAs reviewed five client files, three staff files, and interviewed two staff. Clients were not present to be interviewed.

Based on the observations made during today’s inspection, no deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. An exit interview was conducted, and a copy of this report was left at the facility.

SUPERVISORS NAME: Armando J Lucero
LICENSING EVALUATOR NAME: Claudia Gutierrez
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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