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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800207
Report Date: 01/31/2023
Date Signed: 01/31/2023 02:11:04 PM


Document Has Been Signed on 01/31/2023 02:11 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



FACILITY NAME:GREEN TREE RESIDENCE LLCFACILITY NUMBER:
361800207
ADMINISTRATOR:MARTIN VENTRESS JRFACILITY TYPE:
740
ADDRESS:13741 BURNING TREE DRIVETELEPHONE:
(760) 245-2504
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY:6CENSUS: 3DATE:
01/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Staff Maria VentressTIME COMPLETED:
02:20 PM
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Licensing Program Analyst (LPA) Victoria Chitgian made an unannounced visit to the facility. The purpose of the visit was to conduct a required annual inspection, with an emphasis on infection control due to the COVID-19 pandemic. LPA met with Caregiver Maria Ventress who confirmed that there are no cases/exposures of COVID-19 within the facility. Per review of documents and interview with staff, the facility has not had any cases of COVID-19. At the time of visit there was one (1) staff, and three (3) residents present.

During today's visit, LPA toured the facility and made observations pertaining to the facility's infection control measures. LPA observed proper cleaning and disinfection provisions in place. The facility has submitted a Mitigation Plan as required to the LPAs email address.

LPA requested to inspect the facility's Personal Protective Equipment (PPE) supply, which was limited. LPA observed several boxes of gloves, however one (1) box of surgical masks and two(2) bottles of sanitizer. Over the phone with Administrator Martin, LPA discussed obtaining a full 30-day supply of PPE items such as gowns, surgical masks, N95 masks, disinfectant, and hand sanitizer supply. LPA will issue two(2) Technical Assistance Advisory Notes (TA) for not having a full 30-day supply of PPE. Signage for promoting handwashing, cough/sneeze etiquette, and physical distancing were also not observed. LPA will issue a TA note for lack of signage.

Based on the observations made during todays visit, no health or safety concerns were noted. No deficiencies will be issued per Title 22, Division 6 of the California Code of Regulations. An exit interview was conduced and a copy of this report (LIC 809) and TA notes( LIC 9102) were given to Staff Maria Ventress.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Victoria ChitgianTELEPHONE: (951) 248-0306
LICENSING EVALUATOR SIGNATURE:
DATE: 01/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/31/2023
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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