331880810-11-2-2023-18-AS-JARA-CX7VLC-20231102163144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880810
Report Date: 11/02/2023
Date Signed: 11/02/2023 04:31:53 PM

Document Has Been Signed on 11/02/2023 04:31 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 HOME		FACILITY NUMBER:	331880810
ADMINISTRATOR:	BRANDON MARQUEZ		FACILITY TYPE:	740
ADDRESS:	40052 DAPHNE DRIVE		TELEPHONE:	(909) 994-6204
CITY:	MURRIETA	STATE: CA	ZIP CODE:	92563
CAPACITY:	6	CENSUS: 1	DATE:	11/02/2023
TYPE OF VISIT:	POC	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Staff, Maritza Alfaro Mendoza		TIME COMPLETED:	04:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced visit to the home in order to verify clearance of plans of correction created with Licensee, Sandy Zhao from visit on 10/5/2023. LPA met with staff Maritza Alfaro Mendoza. The following Plan of Correction (POC)s were cleared at the time of the visit: The licensee was cited on 10/5/2023 for 87307(d)(4) Personal Accommodations and Services. Based on observation the licensee did not maintain measures of safety with ramp that lead to back yard that was falling apart. The plan of correction was to repair the ramp. During today's visit. LPA observed the wooden ramp was replaced with a cement ramp and was in good repair. The LPA provided a clearance letter for this deficiency during the visit. 87307(a)(2)(C) Maintenance and Operation. 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. The POC was to remove the items from the room and cease the use as a staff sleeping quarter. During today's visit. LPA found that the bed had been removed from the room and was no longer used as a sleeping quarter. The LPA provided a clearance letter for this deficiency during the visit.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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: 11/02/2023

NARRATIVE

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The licensee was cited on 10/5/2023 for 87465(i) Incidental Medical and Dental. Based on observation the facility has medication that were not destroyed for a prior residents. The POC was to destroy the medication and provide proof of the record. During today's visit the LPA received destruction records for the medications. Clearance letter was provided during the visit.

The following deficiency were not cleared during the time of the visit:
The licensee was cited on 10/5/2023 for 87412(f) Personnel Records. Based on record review and interview, the licensee did not have records for the LPA to review for (1) staff member and no staff training on site. The POC was to send the complete record for house manager, send LPA all staff training, and send LPA all staff COR training. Licensee agreed to send file for house manager by the POC due date. During the visit, LPA observed the staff files still did not have CPR or staff training. The LPA was able to review this information for (3) staff members during the time of the visit as Administrator faxed the records. There are still staff who have incomplete records at the facility. Therefore, the POC was not cleared at the time of the visit. Civil penalties will be assessed in the amount of $100 per day for 21 days.

The licensee was cited on 10/5/2023 for 87309(a) Storage Space. Based on observation the laundry detergent was left unlocked with (1) dementia resident in care. The POC was to send LPA proof of in-service conducted with staff on locking chemicals. LPA did observe the laundry room door was replaced with a locked door knob, however in-service was not provided during the time of the visit. Civil penalties will be assessed in the amount of $100 per day for 27 days.

An exit interview was conducted with licensee over the phone where this report along with civil penalty assessment pages, and appeal rights were reviewed and provided to them. Licensee was advised that civil penalties will continue to accrue until corrections are received by the LPA.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC809 (FAS) - (06/04)

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