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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107204161
Report Date: 07/16/2026
Date Signed: 07/16/2026 02:36:42 PM

Document Has Been Signed on 07/16/2026 02:36 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN GABLES CARE HOME VIIFACILITY NUMBER:
107204161
ADMINISTRATOR/
DIRECTOR:		SHEAKALEE, MARSHAFACILITY TYPE:
740
ADDRESS:1422 ASH AVENUETELEPHONE:
(559) 298-7302
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 6DATE:
07/16/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Designee: Mario RamosTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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On 7/16/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Designee (D1) Mario Ramos . LPAs was granted entry. All 5 residents were present during inspection. Licensee Lorik Sheakalee was present during visit.

LPA toured facility with L1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at 0 degrees F and refrigerator temperature was maintained at 44 degrees F. Fire extinguisher was observed with a purchase date of: 10/17/25. Fire drill last completed on 5/1/26. Washer and dryer observed operational during visit. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature of 109.2 degrees F in bathroom 1, and 117.6 degrees F in bathroom 2. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. All medications were checked and observed kept locked in the hall closet. Residents’ MARS was reviewed. Melatonin 1 mg take 1 tablet orally at bedtime was not listed, labeled or initialed by staff in MAR and is not listed in Centrally Stored Medication Record. First aide kit observed with all of the required items. Samples of residents and a samples of staff files reviewed to have all the required documents.


Deficiencies are being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 7/30/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance-RCFE, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020A)

A copy of this report was provided to Administrator, whose signature on this form confirms receipt of this report.

NAME OF LICENSING PROGRAM MANAGER: See Moua
NAME OF LICENSING PROGRAM ANALYST: Jacques Leffall
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/16/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/16/2026 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 07/16/2026 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN GABLES CARE HOME VII
FACILITY NUMBER: 107204161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(d)(3)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (3) The date and time the PRN medication was taken, the dosage taken, and the resident's response shall be documented and maintained in the resident's facility record.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Melatonin 1 mg take 1 tablet orally at bedtime was not listed, labled or initialed by staff in MAR and is not listed in Centrally Stored Medication Record which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/17/2026
Plan of Correction
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Licensee agrees to have staff complete medication training and submit completion documents to CCLD by POC due date.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 07/16/2026 02:36 PM - It Cannot Be Edited


Created By: Jacques Leffall On 07/16/2026 at 02:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: GREEN GABLES CARE HOME VII
FACILITY NUMBER: 107204161

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/16/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(b)(21)
General Food Service Requirements
(21) Freezers of adequate size shall be maintained at a temperature of 0 degree F (-17.7 degree C), and refrigerators of adequate size shall maintain a maximum temperature of 40 degree F. (4 degree C). They shall be kept clean and food stored to enable adequate air circulation to maintain the above temperatures.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview, record review, the licensee did not comply with the section cited above in Refrigerator temperature tested at 44 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/30/2026
Plan of Correction
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Licensee agrees to have refrigerator repaired or replaced. Licensee agrees to send photos of the temperature of the refrigeratror to recflect 40 degrees F or less to CCLD by POC due date.
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.
See Moua
NAME OF LICENSING PROGRAM MANAGER:
Jacques Leffall
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/16/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2026


LIC809 (FAS) - (06/04)
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