107201446-10-29-2021-24-AS-MYAG-C89NWL-20211029104941

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201446
Report Date: 10/29/2021
Date Signed: 10/29/2021 10:50:01 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	GREEN GABLES CARE HOME II,THE,INC.		FACILITY NUMBER:	107201446
ADMINISTRATOR:	MARIA J. SHEAKALEE		FACILITY TYPE:	740
ADDRESS:	1549 DOUGLAS AVENUE		TELEPHONE:	(559) 297-4152
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 5	DATE:	10/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Marcos Teoanen and Josefina (Josie) Teonen, Caregivers		TIME COMPLETED:	10:20 AM

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On 10/29/2021, Licensing Program Analyst (LPA) Mai Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by caregivers Marcos Teoanen and Josefina (Josie) Teonen. Maria Sheakalee, Administrator was called and state unable to attend meeting. Authorized Marcos Teoanen and Josefina (Josie) Teonen to conduct tour. All five residents were present during the inspection.

LPA conducted tour with caregivers. Facility staffs was observed with mask on. Visitor log-in/temperature check was observed upon entry. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was readily available to residents and visitors. Social distancing is maintained in the common and dining areas. Social distancing postings observed in facility. Cough etiquettes posting not observed in facility.

All resident’s room toured and observed to be adequately furnished and lit. LPA observed 1 shared resident’s bedroom to be at least 6 feet apart, 3 bedrooms that are single occupant, and 1 vacant bedroom that is single occupant. All bathrooms are observed with trash cans with lid and securely fastened grab bars. Bathrooms have non-skid mat. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in laundry cabinet.

The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed residents’ 30-day medication supplies in locked cabinet in kitchen. Food supply was checked and appeared to be an adequate supply. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information. LPA observed a 30-day PPE supplies. LPA observed fire extinguisher served date: 03/11/21.

No deficiencies issued during this inspection.

Exit Interview conducted. The following updated forms/document were requested: Lic 610E, Lic 808, and updated Administrator Certificate. Please submit the above forms to Fresno CCL by: 11/04/21. Administrator and caregivers were informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISOR'S NAME: Melinda Hoffmann	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai Yang	TELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:	DATE: 10/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2021

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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