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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 02/07/2025
Date Signed: 02/07/2025 01:59:58 PM

Document Has Been Signed on 02/07/2025 01:59 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN GABLES CARE HOME IVFACILITY NUMBER:
107201766
ADMINISTRATOR/
DIRECTOR:
SHEAKALEE, LORIKFACILITY TYPE:
740
ADDRESS:385 VARTIKIAN AVENUETELEPHONE:
(559) 298-7986
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 5DATE:
02/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Mario RamosTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explain the purpose of the visit. Caregiver staff called Administrator Lorik Sheakalee and advised that someone was on their way and would be at the home shortly. Mario Ramos came to the home and stated that he is the assistant to the Administrator and assisted me on this inspection (LIC308 on file and current for this staff).
The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPA observed five bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature measured 121.3 degrees F. LPA and staff adjusted the water heater and at end of inspection it was remeasured at 113.9 degrees F. LPA advised to check it monthly.

Kitchen toured, supply of food observed for perishable and nonperishable. Medication and knives are locked in the kitchen area. Laundry room is locked, and stores cleaning supplies Smoke and carbon monoxide, were checked and operating. Fire extinguishers was purchased on 10/14/2024. Last fire drill was completed on 12/08/24. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

Technical Advisories were given on this day. LPA left a current facility roster with staff.

An exit interview was conducted, and a copy of this report was provided to Caregiver staff, Mario Ramos whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 02/17/25: Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage, Updated Facility sketch with emergency meeting locations and all utility shut-offs notated.

Sergiy PidgirnyTELEPHONE: (559) 243-8080
Daiquiri BoydTELEPHONE: 559-243-8080
DATE: 02/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/07/2025
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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