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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880810
Report Date: 10/05/2023
Date Signed: 10/05/2023 04:40:05 PM


Document Has Been Signed on 10/05/2023 04:40 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GREEN MERRYLANDS MURRIETA HOMEFACILITY NUMBER:
331880810
ADMINISTRATOR:BRANDON MARQUEZFACILITY TYPE:
740
ADDRESS:40052 DAPHNE DRIVETELEPHONE:
(909) 994-6204
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY:6CENSUS: DATE:
10/05/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Staff, Dennise GutierrezTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit on 10/4/2023. LPA was granted entry and met with staff, Dennise Gutierrez, who was informed of the purpose of the visit. At the time of the visit there was (1) staff and (1) clients present.

The facility is a one story home with (6) bedrooms and (3) bathrooms with attached garage. No pools or firearms are being kept at the facility. The residents served are elderly ages 60 and over. The facility is approved for a capacity of (6) non-ambulatory residents of which (1) may be bedridden. LPA conducted a tour of the interior and exterior, reviewed facility documents and conducted a staff and resident interviews. LPA observed the following:

Infection Control: The LPA observed hand washing stations in the facility stocked with supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has an infection control plan, however the licensee and staff were unable to show these documents in a timely manner.



Physical Plant: Physical plant, floors, windows, and doors were observed to be clean. Facility is in need of repair, with broken ramp. The smoke detector and carbon monoxide was operational, and the hot water temperature 105.8F. LPA observed unlocked chemicals in the laundry room, this will be cited. LPA observed staff belongings in an unapproved room which is used as a passage way to a restroom. Facility will be cited for this.

Care & Supervision/Administration: The licensee has a staff schedule, however the licensee was unable to provide this to the LPA in a timely manner. Facility sketch, exit routes, personal rights, complaint information and emergency phone numbers were found posted in the facility. The listed administrator, possesses a current administrator's certificate.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN MERRYLANDS MURRIETA HOME
FACILITY NUMBER: 331880810
VISIT DATE: 10/05/2023
NARRATIVE
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Record Review and Resident/Staff Files: LPA reviewed (3) staff files and training. (1) staff does not have CPR on file. Staff training was not provided to the LPA during the time of the visit. (1) staff is currently residing in the home and does not have a staff file at the facility. Two (1) resident file was reviewed, and possessed all required paperwork. The facility will be cited for incomplete staff files.

Health Related Services/ Incidental Medical Services: All client medication was kept locked in facility pantry. The LPA observed medication for Resident #E1 (R1) whom no longer resides at the facility. LPA observed undestroyed controlled medication for the resident is being stored at the facility. Facility will be cited for this.

Due to time constraints, the annual will be continued on a later date. Observations were documented and will be addressed during the annual continuation.

An exit interview was conducted where a copy of this report, 809-D pages and appeal rights were reviewed and provided to staff, Dennise Gutierrez.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 10/05/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN MERRYLANDS MURRIETA HOME
FACILITY NUMBER: 331880810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space
(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the laundry detergent was left unlocked with (1) dementia resident in care. This poses an immediate health, saftey or personal rights risk.
POC Due Date: 10/06/2023
Plan of Correction
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LPA had the staff secure the detergent, the licensee agreed to send the LPA a staff in-service material to conduct with staff, followed by stgaff sign in sheet when it is completed. This will be due on the POC due date.
Section Cited
Criminal Record Clearance
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 10/05/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN MERRYLANDS MURRIETA HOME
FACILITY NUMBER: 331880810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Plan of Operation
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
87307(d)(4)
Personal Accommodations and Services
(4) Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight shall be made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee did not maintain measures of saftey with ramp that lead to back yard that was falling apart. This poses a potential health safety or personal rights risk to residents in care.
POC Due Date: 10/12/2023
Plan of Correction
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The licensee agreed to have this fixed and send proof to the LPA by the POC dued ate.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 10/05/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN MERRYLANDS MURRIETA HOME
FACILITY NUMBER: 331880810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(f)
Personnel Records
(f) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying. Removal of records shall be subject to the following requirements:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interview, the licensee did not have records for the licensee to review for (1) staff member and no staff training on cite. This poses a potential health saftey or personal rights risk.
POC Due Date: 10/12/2023
Plan of Correction
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The licensee agreed to complete the records, send LPA all staff trainings, and send LPA all staff cpr training. Licensee agreed to send file for house manager by the POC due date. The licensee will send a plan on how they will ensure records will be available moving forward.
Section Cited
Personnel Records
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 10/05/2023 04:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN MERRYLANDS MURRIETA HOME
FACILITY NUMBER: 331880810

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/05/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(a)(2)(C)
(a) Living accommodations and grounds shall be related to the facility's function...
(2) Resident bedrooms shall be provided which meet, at a minimum, the following requirements: (C) No bedroom of a resident shall be used as a passageway to another room, bath or toilet.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the licensee was utilizing a room as a staff room which is used as a passage way to a bathroom and license resident room. This poses an immediate personal rights, health or safety risk to residents in care.
POC Due Date: 10/06/2023
Plan of Correction
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The licensee agreed to remove the bed and staff belongings from the room. The licensee is to send proof of this by the POC due date.
Type A
Section Cited
CCR
87465(i)

(i) Prescription medications which are not taken with the resident upon termination of services...shall be destroyed in the facility by the facility administrator and one other adult who is not a resident. Both shall sign a record, to be retained for at least three years, which lists the following:
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation the facility has medication that were not destroyed for a prior residents. This poses an immediate health, saftey or personal rights risk.
POC Due Date: 10/06/2023
Plan of Correction
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The licensee agreed to destroy the medications and maintain a destruction record and send to the LPA by the POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Rikesha StampsTELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira ArreolaTELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6