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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800207
Report Date: 01/11/2024
Date Signed: 01/11/2024 02:14:50 PM


Document Has Been Signed on 01/11/2024 02:14 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: 0DATE:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Maria P Ventress- StaffTIME COMPLETED:
02:26 PM
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On 01/11/24, Licensing Program Analyst (LPA) Michelle Echeverria arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Maria P Ventress and introduced self and stated purpose of the visit. LPA was informed that there are no residents in the facility.

The facility has 3 bedrooms, 2 bathrooms, kitchen, 2 dining areas, living room, laundry, backyard, and attached garage. LPA completed a walk through of facility and review of records.

Physical Plant: The facility is operating in the capacity approved by Community Care Licensing (CCL). There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 73 degrees fahrenheit. LPA inspected resident bedrooms; they are equipped with required furniture such as: mattresses, night stands, storage space, chairs and sufficient lighting. LPA inspected resident bathrooms; bathrooms were clean and appliances were found functional. LPA observed missing rails in the bathroom. Technical violation issued. Water temperatures tested at 113.2 degrees fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide alarms, and first aid kit. Posters such as; the facility license, ombudsman and CCL complaint poster were posted in a common area. LPA observed the personal rights poster missing. Technical violation issued. Cleaning supplies, toxins, sharps, and other dangerous items were kept locked and inaccessible. There was a designated storage space for resident/staff files. There is a locked closet in the hallway that is used for medication storage. There is no swimming pool, bodies of water, firearms or ammunition in the facility. Overall, the facility is clean, in good repair, and operating in safe conditions.

Food Service: Non-perishable and perishable food supply is sufficient. Facility has a wide variety of food available. Dishes, cups, and utensils were also stored properly.
SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207
VISIT DATE: 01/11/2024
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Yards/Outside: One shaded patio, side gate with self-latching handle on the left side of the house that leads into the backyard. All outdoor pathways were free of obstructions.

Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA reviewed administrator file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings. LPA observed an expired administrator's certificate and first aid/cpr certification. Technical violations issued. LPA wasn't able to inspect the resident files, Infection Control Plan, Emergency Disaster Plan, fire drills and liability insurance due to staff not having access. Technical violations issued.

Technical violations were cited during this visit. An exit interview was conducted where this report LIC809, LIC809C and LIC9102TV were discussed and copies were provided to staff, Maria P Ventress.

SUPERVISOR'S NAME: Nedra BrownTELEPHONE: (951) 202-5776
LICENSING EVALUATOR NAME: Michelle EcheverriaTELEPHONE: 951-248-0345
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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