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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107203401
Report Date: 02/04/2022
Date Signed: 02/04/2022 03:08:25 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: 0DATE:
02/04/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Mario Ramos (Daniel), Designated RepresentativeTIME COMPLETED:
02:00 PM
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On 02/04/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a Case Management visit and met with Mario Ramos (Daniel), facility designated representative. Licensee Lorik Sheakalee was called and authorized designated representative to signed and receive report for visit. The purpose of this visit was to conduct a final walk through of the facility. Licensee has surrendered license. No staff and residents present.

LPA toured the facility inside and outside. All bedrooms and bathrooms were empty of personal belongings. There was no indication of persons living in the facility.

Forfeiture to be sent. The facility will be closed effective 02/04/22, pending Licensing Program Manager approval. RO to contact LTCO. Exit interview conducted. Designated representative was informed as COVID-19 precautionary measure, this report will be provided via 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: 02/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2022
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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