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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202858
Report Date: 06/23/2021
Date Signed: 06/23/2021 04:24:49 PM

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:
06/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Supervisor, Mario RamosTIME COMPLETED:
01:05 PM
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On 06/23/2021, Licensing Program Analyst (LPA) Walton arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility. Facility staff contacted the Administrator. Due to a family emergency, the Administrator is unable to attend this inspection. LPA received verbal permission to conduct the facility tour with Supervisor, (S1) Mario Ramos. Facility has one central entry and exit point. Upon entry, LPA observed a visitor screening log. Upon entry to the facility, LPA observed facility staff not wearing facial coverings, however, later during the inspection staff were observed to be wearing facial coverings.

Facility appeared cleaned with no obstruction or fire clearance issues. Hand sanitizer was available to residents and visitors. Social distancing is maintained in the common and cough/sneeze etiquette. Bedrooms were single occupant with 1 shared room. Bathrooms were stocked with paper towels and liquid soap.

LPA checked the medication supply. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable. Cleaning supplies and PPE supplies checked.

LPA will return on a later date to conduct an Annual Continuation to review facility records.

No deficiencies issued during this inspection.

Exit interview conducted. As a COVID-19 precautionary measure, a copy of this report will be provided to Administrator via email and an electronic read receipt confirms receiving this document. Facility Representative signature on file.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Alexandria WaltonTELEPHONE: (559) 246-0128
LICENSING EVALUATOR SIGNATURE:

DATE: 06/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021
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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