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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107204161
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:49:49 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/11/2023 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20231011112134
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: 5DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
09:02 AM
MET WITH:Mario TIME COMPLETED:
12:32 PM
ALLEGATION(S):
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Staff confined resident to their room while in care.
Staff did not ensure that resident's hygiene needs were met while in care
INVESTIGATION FINDINGS:
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On 10/20/2023 Licensing Program Analysts (LPA's) M. Garza and M. Flores arrived at facility for an unannounced complaint visit. LPA met with Direct Care Staff, Joseph and Gamare Whigan. Licensee, Lorik Sheakalee was contacted and stated they were unavailable to come to the facility. LPA was informed Assistant, Mario Ramos would arrive some time later. LPA's completed a tour of the facility inside and out and a health and safety check on residents in care. Residents observed in common areas and in rooms.

During visit LPA's completed interviews with staff and resident(s). LPA's reviewed documentation (physicians reports, needs and assessments, pre-placement appraisal). Interviews with RP and S1 indicated that R1 had hygeine needs were not met. Interview conducted with medical profession indicated that R1 was being confined to their room. The preponderance of evidence standard has been met per Title 22. The allegations listed above are SUBSTANTIATED. Deficiency cited on 9099D.

Exit interview conducted with Licensee, Lorik Sheakalee and Assistant, Mario. A copy of this report and appeal rights given.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: See MouaTELEPHONE: (559) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20231011112134
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 VII, INC.
FACILITY NUMBER: 107204161
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/31/2023
Section Cited
CCR
87411(a)
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87411 Personnel Requirements-General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs…Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
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Licensee to provide in-service training to all staff. In-service sign in sheet and training material to be provided to CCL by POC date. Licensee stated they will be generating a log and provide to CCL.
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This requirement was not met as evidence by: LPA interviews of RP, staff and residents. Interviews indicated that resident was confined to their room and hygeine needs were not being met.
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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) -580-4596
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: 559-365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2