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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201446
Report Date: 12/01/2022
Date Signed: 12/01/2022 09:26:22 AM


Document Has Been Signed on 12/01/2022 09:26 AM - 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, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GREEN GABLES CARE HOME II,THE,INC.FACILITY NUMBER:
107201446
ADMINISTRATOR:ROBERT SHEAKALEEFACILITY TYPE:
740
ADDRESS:1549 DOUGLAS AVENUETELEPHONE:
(559) 297-4152
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
12/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:22 AM
MET WITH:Marcos Teoanen and Josefina (Josie) Teonen, Designated Representative TIME COMPLETED:
09:30 AM
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On 12/1/22, 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 designated representative (designee) Marcos Teoanen and Josefina (Josie) Teonen. Robert Sheakalee, Administrator was called and state unable to attend meeting. LPA conduct tour with designee. All six residents were present during the inspection.

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 and cough etiquettes posting observed in facility. Staff records were reviewed for good health and infection control training. All residents’ records reviewed to have updated emergency contact information.

LPA observed residents’ 30-day medication supplies in locked cabinet in kitchen. Food supply was checked and appeared to be an adequate supply. LPA observed a 30-day PPE supplies. All resident’s room toured and observed to be adequately furnished and lit. LPA observed one shared resident’s bedroom to be at least 6 feet apart, four bedrooms that are 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 fire extinguisher served date: 09/22/22.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 12/7/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9282, current liability insurance, and current Administrator Certificate. A copy of this report was provided to designee.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 12/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/01/2022
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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