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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201556
Report Date: 10/08/2021
Date Signed: 10/08/2021 03:07:03 PM

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 III, INC, THEFACILITY NUMBER:
107201556
ADMINISTRATOR:SHEAKALEE, LORIKFACILITY TYPE:
740
ADDRESS:1573 ASH AVENUETELEPHONE:
(559) 325-3707
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
10/08/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:08 AM
MET WITH:Mario (Daniel) Ramos, Assistant TIME COMPLETED:
12:45 PM
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On 10/08/2021, Licensing Program Analysts (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 Caregiver Analyn Manuel upon arrival. Administrator, Lorik Sheakalee was called and authorized Mario (Daniel) Ramos, Assistant to conduct tour and sign report. Assistant arrived shortly. Facility staff was observed with mask on. All six residents were present during the inspection.

Facility tour conducted with Assistant. LPA observed cough etiquette and COVID-19 social distancing postings. 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. Fire extinguisher has service date of 03/11/21. LPA toured kitchen. LPA observed 14- day supply of nonperishable food and a 2-day supply of perishable food which were stored properly. LPA observed 30-day medication supply stored in a locked cabinet in kitchen. Adequate linen supply observed in hall cabinets. LPA observed bathrooms has trash can with lid. Grab bars and non-skid mat observed in all bathrooms. Hand washing sign were observed by all sinks. LPA observed all 6 bedrooms single occupant furnished and adequately lit. Cleaning supplies were stored and locked in laundry room. The exterior tour was conducted. Side gate was self-closing and self-latching. LPA observed locked gate around body water. All residents’ records reviewed to have updated emergency contact information.

LPA reviewed LIC 808 including Infection control procedures to be implemented and in placed. Copy of completed LIC 808 Mitigation Plan to be submitted to CCL by 10/14/21.

No deficiencies issued during this inspection.

Exit Interview conducted. The following updated forms were requested: LIC 308, LIC 500, LIC 610E, LIC 9020, Theft and Loss Policy and Procedure, current lease contract, and updated Administrator Certificate. Please submit the above forms to Fresno CCL by: 10/14/21. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 10/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021
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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