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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201556
Report Date: 11/17/2023
Date Signed: 11/17/2023 01:39:19 PM


Document Has Been Signed on 11/17/2023 01:39 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
SIERRA CASCADE AC/SC, 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: 4DATE:
11/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mario Ramos, Designated RepresentativeTIME COMPLETED:
01:00 PM
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On 11/17/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Melba Stoops. Administrator Maria Sheakalee was called unable to attend meeting. Designated Representative (designee) Mario “Danny” Ramos was called and arrived shortly. LPA toured facility with designee. All 4 residents were present upon inspection.

The facility was observed to be at a comfortable temperature at 72 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with a service date of:10/12/23. Fire drill last completed on 09/01/23. An adequate supply of perishable and non-perishable food was observed. Medications were checked and observed kept locked in kitchen cabinet. MARS was reviewed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured. All bathrooms were observed operating and functioning during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested 112.6 degrees F. in master bathroom and range between 111.1 and 112.0 degrees F. in bathroom 1. Outside of facility toured. Side gate was observed self-closing and free of debris. Adequate outdoor seating available for residents. All residents’ file reviewed to have required documents. LPA reviewed three staff files to have all required documents, fingerprinted cleared and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational.



No deficiency was cited during inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/28/23. Forms requested: Lic 308, Lic 500, Lic 610E, current Administrator certificate, control of property, and current liability insurance. A copy of this report was provided to designee whose signature on this form confirms receipt of these report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2023
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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