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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203401
Report Date: 09/10/2021
Date Signed: 09/10/2021 03:04:52 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 VI, INC., THEFACILITY NUMBER:
107203401
ADMINISTRATOR:SHEAKALEE, MARSHAFACILITY TYPE:
740
ADDRESS:2460 JOSHUA AVENUETELEPHONE:
(559) 292-3923
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 5DATE:
09/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Mario Ramos, Assistant TIME COMPLETED:
11:30 AM
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On 09/10/2021, Licensing Program Analysts (LPA) Mai Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by Caregiver Sarafin Aguilar. Robert Sheakalee designee representative was called and authorized Mario Ramos (Daniel) assistant to meet and receive report from LPA. Daniel arrived later during tour. All five residents were present during the inspection.

During this inspection a tour of the facility was conducted: All rooms had required furnishings and adequately lit. Passageways were free from obstruction inside and out. No fire hazards observed. Fire extinguisher was charged and service date of 03/01/21. Smoke alarms and carbon monoxide detectors operational. Resident bathroom toured. Securely fastened grab bars and non-skid mats in all tub/shower areas. Kitchen toured, LPA observed a 14- day supply of nonperishable food and a 2-day supply of perishable food which were stored properly. Medications were stored in a locked cabinet. Adequate linen supply observed in hall cabinets. Cleaning supplies were stored and locked in laundry room. The exterior tour was conducted. Side gate was self-closing and self-latching. were kept in a locked cabinet. First Aid Kit checked to have the required items. face coverings and hand washing were observed. Furniture in common and dining areas are spaced to promote distancing. LPAs did not observe 30-day PPE.

LPAs discussed and reviewed LIC 808 including Infection control procedures to be implemented: Daily symptoms screenings (for staff, persons in care and visitors), testing, visitation, quarantine/isolation procedures, emergency staffing plan, PPE storage, use and training, as well as daily infection control procedures. Completed LIC 808 Mitigation Plan to be submitted to CCL by 09/17/21

No deficiencies issued during this inspection.

Exit Interview conducted. The following updated forms were requested: LIC 308 Designation of Facility Responsibility, LIC 500 Personnel Report, LIC 610E Emergency Disaster Plan for Residential Care Facilities For The Elderly, LIC 9020 Register of Facility Clients/Residents, updated Liability Insurance, LIC 309 Administrative Organization, Administrator Certificate, current Liability Insurance, copy of Administrator Certificate. Please submit the above forms/information to Fresno CCL by: 09/17/21.

Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site.

SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Mai YangTELEPHONE: 559-772-7402
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2021
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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