107201556-3-19-2024-24-AS-SPIY-D3JMT2-20240320095250

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107201556
Report Date: 03/19/2024
Date Signed: 03/19/2024 11:45:13 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/12/2024 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240112145413

FACILITY NAME:	GREEN GABLES CARE HOME III, INC, THE		FACILITY NUMBER:	107201556
ADMINISTRATOR:	SHEAKALEE, LORIK		FACILITY TYPE:	740
ADDRESS:	1573 ASH AVENUE		TELEPHONE:	(559) 325-3707
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93611
CAPACITY:	6	CENSUS: 6	DATE:	03/19/2024
		UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Mario Ramos		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Questionable Death
Staff did not report incident to resident's responsible party

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver investigation findings. 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.

The Department investigated the allegations listed above. Based on interviews with staff and facility Administrator (AD), on 12/11/23 Resident (R1) who had Dementia, walked out of the facility overnight without staff knowing. R1 was found by staff laying on the sidewalk and 911 was called. It is unknown how long R1 was outside alone in the cold weather. Record Review of medical records reveal that R1 was hospitalized and passed away at the hospital on 12/15/23. R1’s Death Certificate was obtained and lists R1’s cause of death as Acute Respiratory Failure due to Hypothermic Shock.

See Lic9099C for continuation of this report

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20240112145413

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 03/19/2024

NARRATIVE

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Record review reveals that R1’s daughter had been the primary contact and completed/signed all admission documents. The facility Admission Agreement lists R1’s daughter as the Responsible Party. R1’s daughter was not notified of the incident by the facility. R1’s daughter was not aware that R1 was hospitalized until contacted by the hospital.

Based on interviews and record reviews, The preponderance of evidence standard has been met, therefore both of the above allegations are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

Civil penalties are pending and currently under review. The details of the civil penalties will be outlined in a future report to the facility.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20240112145413

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 87464(f)(1)(c)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined… in (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered… Requirement not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to submit a formal written statement which will include the plan and procedural changes that will be implemented to keep this type of incident from happening again. Training and timeframe to be included. This statement will be submitted to CCLD by POC date.
	8 9 10 11 12 13 14	Licensee did not provide basic services such as care and supervision resulting in R1 exiting the facility without staff knowing. R1 passed away in the hospital. This poses an immediate health, safety or personal rights violation to persons in care.	8 9 10 11 12 13 14
Request Denied Type B 03/26/2024 Section Cited CCR 87466	1 2 3 4 5 6 7	87466 Observation of the Resident The licensee shall ensure that residents are regularly observed... Licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Requirement not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to provide inservice to all staff on the facility procedure of contacting required parties when a resident is sent out or experiences a significant change. A copy of procedure and a sign in sheet with names and signatures of staff will be submitted to CCLD by POC date
	8 9 10 11 12 13 14	Licensee did not ensure that R1's Responsible Party was notified that R1 was taken via ambulance to the hospital after being found by staff to have exited the home and experiencing a fall outside. This poses a potential health, safety or personal rights violation to persons in care.	8 9 10 11 12 13 14

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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