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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201556
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:41:11 AM


Document Has Been Signed on 03/19/2024 11:41 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 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:
03/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Mario RamosTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Deficiencies visit in conjunction with a complaint visit. LPA met with and explained the reason for the visit with facility Designee Mario Ramos. Administrator was unable to come to the facility at the time of the visit.

While conducting a record review in conjunction with a complaint investigation, LPA discovered that Staff (S1) was not cleared to work in the facility. S1 was working during a facility visit on 1/16/2024.

On 1/16/24 LPA Brown contacted and informed the Administrator that S1 was to be immediately removed from the facility. AD visited the Regional Office that same day and was informed that S1 could not be Associated to the facility based on not-eligible status.

A deficiency for Criminal Background Clearance is being cited on the attached 809-D.
Civil penalty is assessed on the attached LIC421BG.

An exit interview was conducted and Plan of Correction was developed. A copy of these reports and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
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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Document Has Been Signed on 03/19/2024 11:41 AM - 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: 03/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
03/20/2024
Section Cited
CCR
87355(e)(1)

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87355(e) (1) 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: (1)Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by:
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AD removed S1 from the facility. S1 cannot return to the facility unless requirements for Criminal Record Clearance is obtained.
DEFICIENCY CLEARED
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Licensee did not ensure S1 had a Criminal Record Clearance. S1 was working on 1/16/24 at the facility. This poses an immediate health, safety or personal rights risk to persons in care.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 03/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/19/2024
LIC809 (FAS) - (06/04)
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