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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201446
Report Date: 11/16/2023
Date Signed: 11/16/2023 11:39:43 AM


Document Has Been Signed on 11/16/2023 11:39 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:
11/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:34 AM
MET WITH:Mario Dan RamosTIME COMPLETED:
12:03 PM
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On 11/16/2023, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required inspection. LPA introduced self, stated purpose of visit and allowed entrance by direct care staff. Administrator and Licensee contacted by telephone and unavailable to conduct today's inspection. Mario Dan Ramos, Supervisor arrived a short time later to meet with LPA Medina.

Facility tour conducted with caregiver. Facility tour began in resident bedrooms. Rooms observed to be sufficiently furnished with adequate lighting. Residents bathrooms observed to be clean and in good repair. Bath/tub are have non-skid mats and grab bars. Hot water tested in both bathrooms with a water temperature of 118 degrees F. Dining room and living room have adequate seating and lighting for all residents in care. Tour of kitchen conducted. LPA observed a two day supply of perishable food and a seven day supply of nonperishable food available. All foods and leftovers stored in the refrigerator and/or freezer observed to be properly stored and labeled. All medications observed to be locked and secured in kitchen cabinet. Medication observed to have all original labels and to be administered as prescribed. All sharps are locked and secured and inaccessible to residents. All cleaning supplies are locked and secured in cabinet in laundry room.

Outside of facility toured. Seating is available for residents, small shed in backyard is locked, secured and inaccessible to residents. All exits observed to be free of obstruction.

Staff and resident files reviewed. No deficiencies observed. Exit interview was conducted, facility report signed and a copy provided for facility records.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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