107201766-2-7-2024-24-AS-MFLS-D28RAT-20240207115141

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 02/07/2024
Date Signed: 02/07/2024 11:52:13 AM

Document Has Been Signed on 02/07/2024 11:52 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME:	GREEN GABLES CARE HOME IV, INC.THE		FACILITY NUMBER:	107201766
ADMINISTRATOR:	SHEAKALEE, LORIK		FACILITY TYPE:	740
ADDRESS:	385 VARTIKIAN AVENUE		TELEPHONE:	(559) 298-7986
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY:	6	CENSUS: 6	DATE:	02/07/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Mario Ramos		TIME COMPLETED:	12:10 PM

NARRATIVE

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Licensing Program Analyst (LPA) M. Flores 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. Licensee Lorik Sheakalee gave consent for this LPA to conduct this visit with Caregiver staff, Mario Ramos.

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 126.4 degrees F.

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 10/12/2023. Last fire drill was completed on 1/15/24. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

During the visit a file review was conducted for residents and staff files, refer to 809D for deficiencies.

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 02/14/24: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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 02/07/2024 11:52 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN GABLES CARE HOME IV, INC.THE	FACILITY NUMBER: 107201766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87309(a)

Storage Space

(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
1 2 3 4	Based on observations and interview the licensee did not comply with the section cited above in 6 out of 6 persons which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/14/2024
	Plan of Correction
1 2 3 4	Licensee will provide a training log on this regulations to the Department by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) -24-0610
LICENSING EVALUATOR NAME: Miriam Flores	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC809 (FAS) - (06/04)

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