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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201556
Report Date: 11/01/2022
Date Signed: 11/01/2022 04:09:37 PM


Document Has Been Signed on 11/01/2022 04:09 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
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:
11/01/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:21 PM
MET WITH:Designee Mario "Daniel” Ramos and Administrator Lorik Sheakalee via telephone TIME COMPLETED:
04:26 PM
NARRATIVE
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On 11/01/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with caregiver Anna Marie Manabat and granted entry. LPA met with caregiver Karen Viernes-Jimenez. Administrator Lorik Sheakalee was called and was unable to attend meeting. Authorized to conduct tour with caregiver. LPA conducted tour of facility with caregiver. Designee Mario Daniel” Ramos later during tour. All six residents were present during the inspection.

Upon entry facility staff was observed with no facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. COVID-19 related and cough etiquette postings observed. LPA observed fire extinguisher served date: 09/22/22.

LPA checked residents’ locked medications. Food supply was checked and appeared to be an adequate supply. LPA observed refrigerated medications stored unlock in refrigerator. LPA observed chemicals stored and unlock in laundry room. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 6 single occupant room. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. Hand washing posting observed by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All resident records reviewed to have updated emergency contact information. LPA observed small amount of PPE supplies in facility.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 107201556
VISIT DATE: 11/01/2022
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A deficiency is being cited on the attached Lic 809D and an immediate Civil Penalty of $500 was assessed. See Lic 421BG is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. Administrator Lorik Sheakalee was called via telephone to discuss Plan of Correction and report. The following documents are requested and submitted to Fresno CCL by: 11/7/22. The following updated forms were requested: Lic 308, Lic 309, Lic 500, Lic 610E, Lic 9282, control of property, and current liability insurance. LPA received a copy of the current Administrator certificate. A copy of this report and appeal rights will be provided via email to Administrator and Designee.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 11/01/2022 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 107201556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:

Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed at approximately 01:49PM, resident’s insulin injections box stored in unlock refrigerator accessible to residents which poses an immediate health, safety or personal rights risk to person in care.
POC Due Date: 11/02/2022
Plan of Correction
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Caregiver and Designee immediately locked medications in medication lock box in refrigerator. POC cleared during visit.
Type A
Section Cited
CCR
87309(a)
Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above when LPA observed at approximately 01:55 PM, two Bleach bottles stored and unlocked in laundry cabinet. Two ambulatory residents were observed in the common area when Bleach bottles was unlocked in the laundry room. Bleach bottles was observed stored and unlocked accessible to residents in care which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Caregiver immediately removed Bleach Bottles into locked cabinet in the laundry room. POC cleared during visit.

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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 3 of 4


Document Has Been Signed on 11/01/2022 04:09 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 107201556

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/01/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
87355(e)(2)
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: (2) Request a transfer of a criminal record clearance…

This requirement is not met as evidenced by:
Deficient Practice Statement
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Base on observation, LPA observed Staff 1 (S1) providing resident care and supervision during inspection. LPA reviewed and confirmed on Facility Personnel Report Summary dated 10/18/22, S1 not associated with facility. S1 is not associated and has been providing resident’s care and supervision which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 11/02/2022
Plan of Correction
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Staff person is to be removed from the facility and not permitted back until associated with facility. POC cleared during visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Melinda HoffmannTELEPHONE: (559) 341-3274
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/01/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/01/2022
LIC809 (FAS) - (06/04)
Page: 4 of 4