<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880543
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:06:48 PM


Document Has Been Signed on 01/22/2024 04:06 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
, CA 92507



FACILITY NAME:GREEN MERRYLANDSFACILITY NUMBER:
361880543
ADMINISTRATOR:BRANDON MARQUEZ-GUTIERREZFACILITY TYPE:
740
ADDRESS:15986 BALTRAY WAYTELEPHONE:
(909) 371-3402
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY:6CENSUS: 4DATE:
01/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Administrator Brandon MarquezTIME COMPLETED:
04:15 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
On 01/22/2024 at 11:04 AM, Licensing Program Analysts (LPAs) Melody Brown, Michelle Echeverria and Bianca Wolcott met with Administrator Brandon Marquez to initiate Case Management Visit. The investigation consisted of observation, interviews, and a review of pertinent documentation.

Per documents review during the facility visit today, 01/22/2024, LPAs Brown, Echeverria and Wolcott reviewed documents and interview staffs and observed that Staff #3 (S3) has criminal background clearance but the Licensee/Administrator did not transfer S3's criminal background clearance to the facility. S3 reported to LPAs Brown, Echeverria and Wolcott that S3 started working at the facility on 01/09/2024. Interviews with Staff #1 (S1) and Staff #2 (S2) confirmed that Staff #4 (S4) had been working at the facility since 01/06/2024 and per documents review, LPAs Brown, Echeverria and Wolcott observed that S4 does not have criminal background clearance and S2 reported to LPAs Brown, Echeverria and Wolcott that S4 started working at the facility on 01/06/2024. LPAs Brown, Echeverria and Wolcott informed Administrator Marquez that deficiency will be issued and Civil Penalties were assessed during the facility visit today, 01/22/2024 with the amount of $200.00 will be assessed for allowing S4 to work at the facility without criminal background clearance and $500.00 for S3 working at the facility without criminal background clearance transfer and will continue to be assessed of $100.00 per day per citation until corrected for for not transferring S3 criminal background clearance to the facility. Moreover, documents review also indicated that the facility does not have the records for Resident #1 (R1) and S2 reported to LPAs Brown, Echeverria and Wolcott that S1 admitted R1 to the facility without any documentation. Deficiency will be issued.

During the tour of the facility, LPAs Brown, Echeverria and Wolcott observed that Resident #2 (R2) has full bedrails and per documents review, R2 was not on hospice and no written documentation from R2's physician indicating the need for full bed rail and no full bed rail exemption was submitted to Community Care Licensing Division (CCLD). Deficiency will be issued. *** Continuation in LIC809C ***
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543
VISIT DATE: 01/22/2024
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
26
27
28
29
30
31
32
Also, during the tour of the facility on 01/22/2024 at 11:20 AM, LPAs Brown, Echeverria and Wolcott observed one (1) knife in the kitchen cabinet, not locked and accessible to clients in care. Deficiency will be issued as this pose immediate health, safety and personal rights risks to residents in care. Furthermore, LPAs Brown, Echeverria and Wolcott observed no first aid book available at the facility. Deficiency will be issued. Moreover, LPAs Brown, Echeverria and Wolcott observed broken drawers in the kitchen cabinet and laundry room. Deficiencies will be issued.

Moreover, LPAs Brown, Echeverria and Wolcott observed that Resident #3 (R3), Resident #4 (R4) and Resident #5 (R5) medications were dispensed but staff at the facility did not update R3, R4 and R5 Medication Administration Record (MAR). Deficiency will be issued. Lastly, during the visit on 01/22/2024, LPAs Brown, Echeverria and Wolcott observed that no Administrator present at the facility during working hours and LPAs Brown, Echeverria and Wolcott had to contact Administrator to go to the facility. Deficiency will be issued. Also, LPAs observed no Administrator present at the facility during working hours. Deficiency will be issued.

Per records review, the facility were cited for the same regulations within 12-month period for CCR 87303(a) and HSC 1569.618(a), civil penalty will be issued today, 01/22/2024 with the amount of $250.00 per repeat violation within 12-month period.

An exit interview was conducted where this report, LIC809, LIC809D, 421BG, 421FC and Appeal Rights were discussed and provided to Administrator Brandon Marquez.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:

DATE: 01/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 01/22/2024 04:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2024
Section Cited
CCR
87355(e)(1)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to not allow S4 to work at the facility without obtaining the required Criminal background clearance and submit copy of Staff Schedule and Personnel Summary Report (LIC500) to LPA Brown at Plan of Correction due date.
8
9
10
11
12
13
14
Based on observation and interview, the Licensee did not comply with the section cited above by not obtaining Staff #4 (S4) criminal record clearance before allowing S4 to work at the facility on 01/06/2024 which pose immediate health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Type B
01/29/2024
Section Cited
CCR87355(e)(2)

1
2
3
4
5
6
7
87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance... This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to transfer S3 criminal record clearance to the facility and submit proof to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on observation and interview, the Licensee did not comply with the section cited above by not transferring Staff #3 (S3) criminal record clearance to the facility before allowing S3 to work at the facility on 01/09/2024 which poses potential health, safety and personal rights risk to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/22/2024 04:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/23/2024
Section Cited
CCR
87465(a)(6)

1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87465(a)(6) and submit proof of All Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation, interviews and records review, the Licensee did not comply with the section cited above by not updating R3, R4 and R5 Medication Adminisitration Record (MAR) after dispensing R3, R4 and R5 medications per their physician's order which pose immediate health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14
Type A
01/23/2024
Section Cited
CCR87309(a)(1)

1
2
3
4
5
6
7
87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87309(a)(1) and submit proof of Staff Training Log to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the LIcensee did not comply with the section cited above by not locking the one (1) knife at the kitchen cabinet making it accessible to residents in care which pose immediate health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 01/22/2024 04:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2024
Section Cited
CCR
87303(a)

1
2
3
4
5
6
7
87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety...This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee stated to repair the broken cabinet in the kitchen and in the laundry room and submit proof to LPA Brown at Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation and interview, the Licensee did not comply with the section cited above by not having the kitchen cabinet and laundry cabinet in good repair which pose potential health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14
Type B
01/29/2024
Section Cited
HSC1569.618(a)

1
2
3
4
5
6
7
HSC 1569.618 Administration and management of residential care facilities; substituted qualifications; employee scheduling (a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to submit Signed Statement of Understanding on HSC 1569.618 and submit to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having an Administrator present during working hours at the facility which pose potential health, safety and personal rights risks to residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 01/22/2024 04:06 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507


FACILITY NAME: GREEN MERRYLANDS
FACILITY NUMBER: 361880543

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/29/2024
Section Cited
CCR
87506(e)

1
2
3
4
5
6
7
87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87506(e) and submit proof of Staff Training Log to LPA Brown at Plan of Correction (POC) due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by not having Resident #1 (R1) record at the facility which poses potential health, safety and personal rights risks to resident in care.
8
9
10
11
12
13
14
Type B
01/29/2024
Section Cited
CCR87608(a)(5)(B)

1
2
3
4
5
6
7
87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions (5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:

1
2
3
4
5
6
7
Licensee stated to train all staff on CCR 87608(a)(5)(B) and submit proof of training log to LPA Brown at POC due date.
Administrator will remove R2 full bed rail and submit proof to LPA Brown at POC due date.
8
9
10
11
12
13
14
Based on observation, interview and records review, the Licensee did not comply with the section cited above by allowing Resident #2 (R2) to have full bed rail at the facility which pose potential health, safety and personal rights risks to resident in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 202-6356
LICENSING EVALUATOR NAME: Melody BrownTELEPHONE: 951-897-2187
LICENSING EVALUATOR SIGNATURE:
DATE: 01/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/22/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6