<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202858
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:41:58 PM

Document Has Been Signed on 07/07/2021 03:41 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN GABLES CARE HOME V, INC., THEFACILITY NUMBER:
107202858
ADMINISTRATOR:SHEAKALEE, LORIKFACILITY TYPE:
740
ADDRESS:1962 ELLERY AVENUETELEPHONE:
(559) 323-3928
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
07/07/2021
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
12:49 PM
MET WITH:Supervisor, Mario RamosTIME COMPLETED:
02:05 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 07/07/2021, Licensing Program Analyst (LPA) arrived unannounced to conduct a Case Management - Annual Continuation. LPA contacted Administrator Lorik Sheakalee via telephone and stated the purpose of the visit. Administrator is unable to attend this inspection. LPA received verbal permission to meet with Supervisor, Mario Ramos.

The purpose of today's visit is to continue the Annual Inspection conducted on 06/23/2021.

During the Annual Inspection on 06/23/2021, LPA observed facility staff without facial coverings while providing and supervision to clients in care. Upon entry to the facility on 07/07/2021, LPA observed facility staff not wearing facial coverings while providing care and supervision to clients, in violation of official government orders requiring the wearing of face coverings while working under specified conditions.

During today's inspection, staff records were reviewed for good health and infection control training. Residents wear masks when away from the community. Resident’s files have updated emergency contact information. Administrator certification is current.

Based on observation, a deficiency is being cited in accordance with the California Code of Regulations, Title 22, Division 6, Chapter 8, Section 87468.1.

An exit interview was conducted and a Plan of Correction was reviewed and developed via telephone with Adminsitrator, Lorik Sheakalee. Administrator was informed that as a COVID-19 precautionary measure, this report and appeal rights will be provided via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/07/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 07/07/2021 03:41 PM - It Cannot Be Edited


Created By: Alexandria Walton On 07/07/2021 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN GABLES CARE HOME V, INC., THE
FACILITY NUMBER: 107202858

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, the licensee did not comply with the section cited above when LPA observed 2 out of 2 staff members on duty without facial coverings while providing care and supervision to residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/08/2021
Plan of Correction
1
2
3
4
Staff immediately donned facial coverings upon request. Licensee agreed to conduct a training on the above section with facility staff to ensure staff are wearing facial coverings while oroviding care and supervision. Proof of traning will be submitted to the Fresno CCL office by 08/09/2021. POC cleared during visit.
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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 07/07/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/07/2021


LIC809 (FAS) - (06/04)
Page: 2 of 2