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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361880899
Report Date: 03/10/2025
Date Signed: 04/17/2025 09:52:48 PM

Document Has Been Signed on 04/17/2025 09:52 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 WILLOW HOME CAREFACILITY NUMBER:
361880899
ADMINISTRATOR/
DIRECTOR:		ROSEMARIE SUMADSADFACILITY TYPE:
740
ADDRESS:950 S WILLOW AVETELEPHONE:
(909) 835-8706
CITY:RIALTOSTATE: CAZIP CODE:
92376
CAPACITY: 6CENSUS: 5DATE:
03/10/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:18 PM
MET WITH:Miguelito Veluz, caregiverTIME VISIT/
INSPECTION COMPLETED:
06:45 PM
NARRATIVE
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Licensing Program Analyst, LaVette Farlow, (LPA) arrived at the Green Willow Home Care Facility unannounced to conduct the Annual Inspection. LPA knocked on the door and was greeted by Care Staff, Cecilia Plagata and granted entry. LPA introduced self and stated purpose of the visit. Administrator, Arminda Lopez was notified of my arrival by Care Staff, Miguelito Veluz.

LPA was accompanied by Miguelito Veluz and Cecilia Plagate during the tour of the inside and outside, and observed the following:

Facility: The Facility is licensed for six (6) non-ambulatory adults, 1 bedridden and a Hospice Waiver for 6 residents. LPA observed that the facility is operating in the capacity and conditions approved by Community Care Licensing (CCL).
Physical Plant: LPA Farlow observed the facility's temperatures to be maintained comfortable temperature. The facility is comprised of 2 Living Rooms, Dining Rooms, Resident/Staff Rooms, Bathrooms, Kitchen, Backyard and attached garage. Resident Room contained all required furnishings. Restrooms are maintained for staff and residents. Each bathrooms included operable appliances, adequate paper supplies, non-slip grip materials and handrails. Extra supplies of linens, towels, hygiene supplies were located in the bathroom and some in the garage. The facility was sufficiently lit by various lamps and night lights throughout the facility. The facility is equipped with operable fire/smoke alarms, carbon monoxide detectors. Fire Extinguisher was located in the kitchen; and last inspected January 2024. Staff Miguelito, stated the fire department was here in January 2025 and adjusted the mounting of the fire extinguisher on the wall. Licensee will provide proof of service. The facility's Emergency Disaster Plan, Facility Sketch and Evacuation Plan was reviewed; as it was posted in a prominent place. LPA observed the emergency or disaster plan had not been reviewed and signed since 2/16/2023.

Kitchen/Food Service: LPA observed the food supply; the amount of perishable food is sufficient for number of residents in care. The nonperishable and can good is not sufficient for resident in care. A technical violation issued. LPA's visit was during dinner. LPA witnessed food prepared and stored properly. Sharp objects were secure and inaccessible to residents in care.
Please see LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/10/2025
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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Document Has Been Signed on 04/17/2025 09:52 PM - It Cannot Be Edited


Created By: Lavette Farlow On 03/10/2025 at 05:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: GREEN WILLOW HOME CARE
FACILITY NUMBER: 361880899

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/10/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
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:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by ensuring that all staff are fingerprinted and criminal background cleared prior to working in the facility for 2 out of 4 staff files reviewed staff were not cleared, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/31/2025
Plan of Correction
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LIcensee agrees to dismiss any staff not fingerprint and criminal background cleared from working until the staff received to official approval to work in such facility by POC date. Licensee also agrees to associate such staff to this facility roster by POC date.
Type A
Section Cited
CCR
87465(a)(6)
Incidental Medical and Dental Care Services
(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:
Deficient Practice Statement
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Based on observation, interview, and record review, the licensee did not comply with the section cited above by not ensuring 1 out of 2 residents MARS is accurate and all prescribed medication is listed on the MARS for review by CCLD, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/24/2025
Plan of Correction
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LIcensee agrees to submit and complete a training log/attendance for all staff who administer medication to resident in care. Also, licensee agrees to ensure all staff review the regulations acknowledging knowledge and understanding of the procedures of logging medication, documenting medication etc by POC date. Licensee agrees to email this to LPA/ CCLD.
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:Nedra Brown
LICENSING EVALUATOR NAME:Lavette Farlow
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2025


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 WILLOW HOME CARE
FACILITY NUMBER: 361880899
VISIT DATE: 03/10/2025
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Garage - In the facility's attached garage, LPA observed the emergency food supply was well stocked. LPA also observed that the facility centrally stores medications securely in this area.
Care & Supervision: Facility has sufficient care staff; who also reside on facility grounds. toxic items are inaccessible to residents in care and stored and locked in a filing cabinet in the office.

Record Review of Resident/Staff Files: LPA reviewed records for two (2) residents in care. Resident records are all complete with updated Physician's Reports, Admissions Agreements, Appraisals and Needs and Services Plans. LPA reviewed 4 (four) out of 4 four (4) staff files. LPA observed that three (3) of the staff records reflect current CPR/First Aid Certification, Personnel Records and Health Screenings. LPA observed the two (2) out of two (2) staff was not Criminal Record Cleared and or fingerprinted. A deficiency was cited and civil penalties will be assessed. The Administrator's Administrator Certificates were posted and observed in good standing.

Signs/Posters: LPA observed the following signs posted in a prominent place: Facility Sketch Disaster Plan, Long Term Care Ombudsman, Resident Rights, Resident Council, Theft and Loss Policy, Staff Roster, Visiting Hours, Daily Schedule and facility license are posted in the hallway of the facility. Emergency or Disaster Plan was posted, but had not been reviewed and signed since 2/2023. A technical violation issued.

Medication/Medical Related Services: LPA observed that the resident's medications are centrally stored and secure in file cabinets in the kitchen and garage. LPA reviewed 2 out of 2 resident's medications and compared it to the facility's Medication Administration Report (MARS) and Centrally Stored Medication Log. LPA found 1 out of 2 residents MARS was incomplete with the prescription medication being logged onto the MARS. A deficiency was cited.

Based on observations, staff interviews, and records review two deficiencies and two technical violation were cited during the visit. An exit interview was conducted Per California Code of Regulations, (Title 22, Division & Chapter 6), are being cited on the attached LIC809D and a civil penalty will be assessed in the amount of $800.
An exit interview was conducted where this report LIC809, LIC809C, LIC809D, LIC9102TV, LIC421BG and appeal rights was reviewed, discussed the provided to the facility representative Melona B. Whitelaw and Administrator, Arminda Lopez.
NAME OF LICENSING PROGRAM MANAGER: Nedra Brown
NAME OF LICENSING PROGRAM ANALYST: Lavette Farlow
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2025
LIC809 (FAS) - (06/04)
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