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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880810
Report Date: 03/23/2023
Date Signed: 03/23/2023 04:05:55 PM

Document Has Been Signed on 03/23/2023 04:05 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GREEN MERRYLANDS MURRIETA HOMEFACILITY NUMBER:
331880810
ADMINISTRATOR:ZHAO, NAFACILITY TYPE:
740
ADDRESS:40052 DAPHNE DRIVETELEPHONE:
(909) 994-6204
CITY:MURRIETASTATE: CAZIP CODE:
92563
CAPACITY: 6CENSUS: 0DATE:
03/23/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:36 PM
MET WITH:No representative available for signatureTIME COMPLETED:
04:15 PM
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Licensing Program Analysts (LPAs) Janira Arreola and Sara Martinez conducted an unannounced visit to the facility in order to conduct a case management after being notified by the Local Long Term Care Ombudsmen that the home appeared to be unoccupied.

LPAs arrived at the facility at 3:36 pm and rang the door bell. LPAs observed the weeds in the front yard were over grown and no cars were observed in the drive way. LPAs received no answer from the facility, and attempted to call both phone numbers on the facility profile. LPA Arreola left (2) voicemail's, one on each phone number.

LPAs attempted to look into the facility windows, however the blinds were shut and LPAs were unable to see if any resident belongings or residents were inside.

This report will be mailed to the Licensee and to the mailing address listed on file by tomorrow 3/23/2023 COB 5:00 pm.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 03/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/23/2023
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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