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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204161
Report Date: 09/03/2021
Date Signed: 09/03/2021 12:29:19 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 VII, INC.FACILITY NUMBER:
107204161
ADMINISTRATOR:SHEAKALEE, MARSHAFACILITY TYPE:
740
ADDRESS:1422 ASH AVENUETELEPHONE:
(559) 298-7302
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY:6CENSUS: 6DATE:
09/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Robert Sheakalee , Designee RepresentativeTIME COMPLETED:
12:45 PM
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On 09/03/2021, Licensing Program Analysts (LPAs) M. Yang and K. Brown arrived unannounced to conduct an Annual Inspection - Infection Control. LPAs introduced self, stated the purpose of the visit, and requested to meet with the Administrator. LPA was met by Caregiver Nelia Rosete. Robert Sheakalee, Designee Representative was called and arrived later. All six residents were present during the inspection.

LPA conducted a complete tour of the facility with Administrator and caregiver. The facility was observed without any fire clearance issues or obstruction. Common areas had furniture and was lit. The resident’s rooms were toured and were observed with required furniture. LPAs toured resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Bathrooms were clean and had secure grab bars and nonskid mats in showers. Cleaning supplies and chemicals were observed in the locked garage. LPAs did not observed 30-day PPE. Medications were kept in a locked cabinet. First Aid Kit checked to have the required items. LPAs observed a 14- day supply of nonperishable food and a 2-day supply of perishable food which were stored properly.

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 09/10/21

No deficiencies issued during this inspection.

Exit Interview conducted. The following 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, LIC 309 Administrative Organization, current Liability Insurance, copy of Administrator Certificate. Please submit the above forms/information to Fresno CCL by: 09/7/21.

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

DATE: 09/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2021
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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