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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004801
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:44:33 AM

Document Has Been Signed on 08/29/2024 11:44 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
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:GREEN PINES HOME, INC.FACILITY NUMBER:
306004801
ADMINISTRATOR/
DIRECTOR:		MARTINEZ, SHELLYFACILITY TYPE:
735
ADDRESS:509 ADAMS AVETELEPHONE:
(714) 478-0695
CITY:FULLERTONSTATE: CAZIP CODE:
92832
CAPACITY: 6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
07:05 AM
MET WITH:Administrator, Shelly MartinezTIME VISIT/
INSPECTION COMPLETED:
11:50 AM
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On 8/29/2024, Licensing Program Analyst (LPA) Jenifer Tirre conducted an unannounced required visit using the CARE Inspection Tool. LPA was greeted by caregiver and granted entry after stating the purpose of the visit. Administrator (AD) Shelly Martinez was present to assist with the facility inspection on today's date.

The facility is licensed for six (6) Ambulatory Developmentally Disabled Clients. Facility is a level three home.

Facility is a single story with attached garage facility. The facility has Four bedrooms (Three shared client bedrooms and one staff room), and two full bathrooms.

At around 7:10AM LPA conducted client and staff file reviews. At around 9;00AM, LPA conducted a tour of the physical plant accompanied by Administrator Shelly Martinez, and the following was observed: There were no bodies of water on the premises. All rooms were inspected. Beds and bedding supplies were in operational condition, lighting was provided, and storage for the client's personal belongings was observed. Bed linens, comforters, and bath towels were available during the visit. Bathrooms were operational with water temperature measured at 118.2 degrees F. A comfortable temperature of 73 degrees F. was maintained in the facility.



LPA observed the facility to be furnished at the time of the visit. Storage areas for personal hygiene products was observed. Sharps objects and toxins were secured in cabinet and not accessible to clients. The kitchen was inspected, and sufficient perishable and non-perishable food was maintained adequately. Facility has operational fridge, gas stove and microwave. Facility has supply of emergency food and water. Facility has one fire extinguisher which was mounted and fully charged. A review of the Medication Records Administration (MAR) was conducted, and LPA observed the records are in compliance.

CONTINUED ON 809C
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
ORANGE COUNTY RO, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME: GREEN PINES HOME, INC.
FACILITY NUMBER: 306004801
VISIT DATE: 08/29/2024
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During the visit, LPA observed the facility's infection control practices. LPA observed screening protocols for visitors, staff, and residents, and sanitizing stations in common areas and restrooms. LPA observed the facility has a 30-day supply of Personal Protective Equipment (PPE). All mandated inspection control posters were posted.

LPA observed First Aid Kit was maintained. A working land line phone was operational. The last fire drill was conducted on August 1, 2024. The facility had operational smoke and carbon monoxide detectors in bedrooms and common areas. The facility has current liability insurance on file effective 4/2/2024 - 4/2/2025.
A review of Six Clients (C1-C6) service files and three staff (S1-S3) personnel files revealed to be complete. The facility has the current administrator's certification on file for Shelly Martinez # 6022389735 - Expiration 1/14/2025.

No deficiencies during this inspection visit.

An exit interview was conducted with Administrator, and a copy of the report was provided.
SUPERVISORS NAME: Lourdes Montoya
LICENSING EVALUATOR NAME: Jenifer Tirre
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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