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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107202858
Report Date: 05/24/2024
Date Signed: 05/24/2024 01:51:39 PM


Document Has Been Signed on 05/24/2024 01:51 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
SIERRA CASCADE AC/SC, 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: 7DATE:
05/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Mario “Danny” Ramos, Assistant TIME COMPLETED:
02:15 PM
NARRATIVE
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On 05/24/24, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual
Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with staff Teresita Delatorre, Mario “Danny” Ramos, Assistant arrived shortly. All seven residents were present during the inspection.

The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway


obstructions or fire hazards were observed inside. All residents’ and staffs’ files reviewed. Fire extinguisher observed with purchased date 10/12/23. Medications were checked and observed kept locked in kitchen cabinet. Resident’s MARS was reviewed.

Small live roaches were observed on the kitchen counter and on the toilet in bathroom 1. Assistant stated pest control have been schedule to come out on 05/24/24 at 2:00PM. Records of the pest control service will be submitted to LPA.

An adequate supply of perishable and non-perishable food was observed. All residents’ bedrooms were toured. LPA observed single occupant in bedroom 1, single occupant in bedroom 2, single occupant in bedroom 3, single occupant in bedroom 4, and 3 resident’s bed in shared bedroom 5. LPA observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are observed with securely fastened grab bars. Hot water temperature was tested range 115.3 and 116.2 degrees F. in bathroom and range 114 and 113.8 degrees F in shared bedroom bathroom. Toilet was observed functioning and operational. Cleaning chemicals observed locked in the laundry room.

Outside of facility toured and observed free of debris with adequate outdoor seatings. Side gate was observed self-closing and self-latching. Carbon monoxide and smoke detectors were tested and observed to be operational.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
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 05/24/2024 01:51 PM - 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
SIERRA CASCADE AC/SC, 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87204(a)
87204 (a) A licensee shall not operate a facility beyond the conditions and limitations specified on the license, including specification of the maximum number of persons who may receive services at any one time. An exception may be made in the case of catastrophic emergency when the licensing agency may make temporary exceptions to the approved capacity.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interviews conducted, and records reviewed, the facility is a capacity of 6 and 7 residents was observed reside at the facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee is to submit a plan to Fresno CCL by POC due date 05/25/24 on relocation of the 7th resident.
Type A
Section Cited
CCR
87465(c)(2)
87465 (c)(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:

Deficient Practice Statement
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Based on interviews, records review, and observation, MARs were reviewed, and medications were audit and shown that staff did not administer medications for R1 and R2 as directed by physician, which poses an immediate health and safety risk for the person in care.

Licensee shall have staff be retrained on administering medications. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 06/06/24.
POC Due Date: 05/25/2024
Plan of Correction
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Licensee shall submit documents of steps the facility will take to ensure facility meets the regulation on administering medications as directed by physician to Fresno CCL office by POC due date 05/25/24.

Licensee shall have staff be retrained on administering medications. Licensee will submit documentation of training topics which include process of administering medications with staff attendance rooster to the Fresno CCL office by 06/06/24.

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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/24/2024 01:51 PM - 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
SIERRA CASCADE AC/SC, 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
87458(b)(1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on records reviewed, 5 out of 7 residents do not have TB result on file which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee will submit proof of TB result for 5 of the residents to Fresno CCL by POC due date 6/6/24.
Type B
Section Cited
HSC
1796.45
HSC 1796.45 TB Testing (a) Affiliated home care aides hired on or after January 1, 2016, shall submit to an examination 90 days prior to employment, or within seven days after employment, to determine that the individual is free of active tuberculosis disease.

This requirement is not met as evidenced by:
Deficient Practice Statement
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LPA reviewed S1 did not have a TB result on file which poses a potential risk to the health and safety of the residents.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee shall ensure all staff have a TB result on file. S1 TB result shall be submitted to the Fresno CCL office by POC due date 6/6/24.
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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 4 of 8


Document Has Been Signed on 05/24/2024 01:51 PM - 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
SIERRA CASCADE AC/SC, 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: 05/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(c)(3)
87465 (c)(3) A record of each dose is maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and records reviewed, R1’s medication Quetiapine Fumarate 50 mg had been administered by staff and not documented in the resident’s MARs. R2’s medication Pantopraxole Sod Dr 40 mg had been administered by staff and not documented in the resident’s MARs, which poses a potential health and safety risk for the person in care.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee shall have staff be retrained on documentation of medications. Licensee will submit documentation of training topics which will include trains of documentation in the residents’ MARs with staff attendance rooster to the Fresno CCL office by 06/06/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:
DATE: 05/24/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/24/2024
LIC809 (FAS) - (06/04)
Page: 5 of 8


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GREEN GABLES CARE HOME V, INC., THE
FACILITY NUMBER: 107202858
VISIT DATE: 05/24/2024
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A deficiency and an immediate Civil Penalty of $500 was assessed. See Lic 421IM is being cited on the attached Lic 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 05/30/24. The following updated forms were requested: Lic 308, Lic 500, Lic 610E, current Administrator Certificate, and current liability insurance. A copy of this report and appeal rights was provided to Assistant, whose signature on this form confirms receipt of this report.
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -65-7912
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 05/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2024
LIC809 (FAS) - (06/04)
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