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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202858
Report Date: 04/26/2022
Date Signed: 04/26/2022 06:42:50 PM


Document Has Been Signed on 04/26/2022 06:42 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:
04/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:15 PM
MET WITH:Mario “Danny” Ramos,Designated representative TIME COMPLETED:
07:00 PM
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On 4/26/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with administrator. LPA met with Teresita Delatorre, Caregiver. Administrator was called. Mario “Danny” Ramos, Designated representative was called and arrived shortly and conduct tour with LPA. All six residents were present during the inspection.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to residents and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. Social distancing postings not observed. LPA observed cough etiquette postings.

LPA checked residents’ locked medications. LPA observed 30 days PPE supplies. Food supply was checked and appeared to be an adequate supply. LPA observed chemicals secured in laundry room locked with plastic security door knob. All resident’s room toured and observed to be adequately furnished and lit. LPA observed 4 bedrooms that are single occupant and one shared client’s bedroom to be at least 6 feet apart. All bathrooms are observed with securely fastened grab bars and non-skid mat. All bathrooms observed trash bin with lid. LPA observed hand washing posting by bathroom sinks.

The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. Five of six resident records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 5/2/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 610E, Lic 808, Lic 9020, update Administrator certificate and control of property. LPA received copy of current liability insurance. A copy of this report was provided to Administrator.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 04/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/26/2022
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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