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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 361880543
Report Date: 01/22/2024
Date Signed: 01/22/2024 04:04:43 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/16/2024 and conducted by Evaluator Melody Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20240116115558
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
UNANNOUNCEDTIME BEGAN:
11:04 AM
MET WITH:Administrator Brandon MarquezTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility staff refused to accept a resident back after hospitalization.
INVESTIGATION FINDINGS:
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On 01/22/2024 at 11:04 AM, Licensing Program Analysts (LPAs) Melody Brown, Michelle Echeveria and Bianca Wolcott arrived at the facility to investigate a complaint and deliver the findings for the above complaint allegation. Upon arrival, LPAs Brown, Echeverria and Wolcott met with a Staff #3 (S3). Administrator Brandon Marquez was contacted and informed of the visit. LPAs Brown, Echeverria and Wolcott informed S3 of the purpose of the visit.

The investigation consisted of file review and interviews with relevant parties. LPAs Brown, Echeverria and Wolcott conducted interviews, and reviewed facility files. The allegation indicates Facility staff refused to accept a resident back after hospitalization. S1 reported that they did not pick-up Resident #1 (R1) from the hospital because they do not have staff at the facility to provide care and supervision for R1 as Staff #4 (S4) had an injury and unable to work. Staff #2 (S2) reported to LPAs Brown, Echeverria and Wolcott that the hospital did not call S2 that R1’s ready for discharged but they called S1.
*** Continuation in LIC9099C ***
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20240116115558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
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Per interviews and file review, LPAs Brown, Echeverria and Wolcott observed that the facility did not accept R1 back from the hospital even after S1 was notified of R1's discharged on 01/12/2024. LPAs Brown, Echeverria and Wolcott will be issuing a citation. In addition, LPA Brown contacted hospital social worker in Fontana and Riverside and both social worker's reported that the facility refused to accept R1 back at the facility after informing S1 that R1's ready for discharged. Per investigation conducted today, 01/22/2024, R1's now living at a residential care facility for the elderly (RCFE) in the city of Hemet, California with move in date of 01/20/2024.

Based on LPA Brown, Echeverria and Wolcott observations and interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore, the allegation of Facility staff refused to accept a resident back after hospitalization is SUBSTANTIATED. California Code of Regulations, Title 22, Division 6, Chapter 8 is cited on the attached LIC9099D.

An exit interview was conducted where this report (LIC 9099), LIC9099D, and Appeal Rights were discussed and provided to Administrator Brandon Marquez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
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
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20240116115558
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
87224(a)
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87224 Eviction Procedures (a) The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required … Licensee did not meet this requirement as evidenced by:
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Licensee stated to review Title 22, Section 87224(a) and write a self-certification that the regulation has been read and is understood. and submit to LPA Brown by Plan of Correction (POC) due date.
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Based on interviews, record review and observations, the Licensee refused to accept R1 back to the facility upon hospital discharge. This posed a potential Health, Safety or Personal Rights risk to residents in care.
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
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
LIC9099 (FAS) - (06/04)
Page: 3 of 3