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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361800207
Report Date: 11/04/2024
Date Signed: 11/04/2024 02:21:24 PM

Document Has Been Signed on 11/04/2024 02:21 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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GREEN TREE RESIDENCE LLCFACILITY NUMBER:
361800207
ADMINISTRATOR/
DIRECTOR:		MARTIN VENTRESS JRFACILITY TYPE:
740
ADDRESS:13741 BURNING TREE DRIVETELEPHONE:
7602452504
CITY:VICTORVILLESTATE: CAZIP CODE:
92395
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 0DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:50 AM
MET WITH:Maria Ventress, CaregiverTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 11/04/24, Licensing Program Analyst (LPA) Eldin Serrano arrived unannounced to conduct the required annual visit to the facility. LPA met with Staff, Maria 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 74 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 grab bars in the bathroom. Citation will be issued. Water temperatures tested at 116.6 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. Cleaning supplies, toxins, and other dangerous items were kept locked in the garage 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 and sharp items. 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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351
DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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 ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207
VISIT DATE: 11/04/2024
NARRATIVE
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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. Citation will be issued. LPA wasn't able to inspect the Infection Control Plan, Emergency Disaster Plan, fire drills and liability insurance due to staff not having access. .

Citations were issued during this visit. An exit interview was conducted where this report LIC809, LIC809C, LIC809D and Appeal Rights were discussed and copies were provided to staff, Maria P Ventress.

SUPERVISOR'S NAME: Karen ClemonsTELEPHONE: (951) 836-2784
LICENSING EVALUATOR NAME: Eldin SerranoTELEPHONE: 951-248-0351
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not ensuring that the Infection Control Plan is available for review. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Licensee stated that he will submit proof of Infection Control Plan by the planc of correction (POC) due date.
Section Cited
Other Provisions
On and after July 1, 2015, all residential care facilities for the elderly, except those facilities that are an integral part of a continuing care retirement community, shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate, caused by the negligent acts or omissions to act of, or neglect by, the licensee or its employees.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having a copy of the liability insurance available for review. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Licensee stated that he will submit a copy of the liability insurance 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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having in administrator's file an updated first aid/CPR certification. which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Licenseee stated that he will submit the updated CPR/first aid certification by the plan of correction (POC) due date.
Section Cited
Personnel Records
(d) The licensee shall maintain documentation that an administrator has met the certification requirements specified in Section 87406, Administrator Certification Requirements or the recertification requirements in Section 87407, Administrator Recertification Requirements.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above by not having an updated Administrator's certificate which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Licensee stated that he will submit an updated Administrator's certificate 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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/04/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Other Provisions
(a)In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the Emergency Disaster Plan available for inspection/review, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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LIcensee stated that he will submit the required Emergency Disaster Plan by the plan of correction (POC) due date.
Section Cited
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not conducting the required emergency disaster drill which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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Licensee stated that he will submit proof of the required Emergency Disaster Drill 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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
Page: 5 of 7
Document Has Been Signed on 11/04/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Emergency Disaster Plan
(c) Emergency exiting plans and telephone numbers shall be posted.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the required emergency exiting plans and telephone numbers posted at the facility which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/18/2024
Plan of Correction
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LIcensee stated that he will submit proof of the required emergency exiting plan and telephone numbers by the plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
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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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
Page: 6 of 7
Document Has Been Signed on 11/04/2024 02:21 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507


FACILITY NAME: GREEN TREE RESIDENCE LLC
FACILITY NUMBER: 361800207

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024
DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited

Water supplies and plumbing fixtures shall be maintained as follows: Grab bars shall be maintained for each toilet; bathtub and shower used by residents.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above by not having the required grab bars for each toilet and bathtub which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/04/2024
Plan of Correction
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Licensee stated that he will submit proof of installation of the required grab bars by the plan of correction (POC) due date.
Section Cited
Deficient Practice Statement
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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.
Karen ClemonsTELEPHONE: (951) 836-2784
Eldin SerranoTELEPHONE: 951-248-0351

DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024

LIC809 (FAS) - (06/04)
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