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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206562
Report Date: 02/20/2024
Date Signed: 02/20/2024 03:12:13 PM


Document Has Been Signed on 02/20/2024 03:12 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



FACILITY NAME:GREEN VILLAFACILITY NUMBER:
107206562
ADMINISTRATOR:SANTOS, CARLOSFACILITY TYPE:
740
ADDRESS:1463 W. SIERRATELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY:6CENSUS: 6DATE:
02/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Carlo SantosTIME COMPLETED:
03:22 PM
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On 2/20/204, Licensing Program Analyst (LPA) M. Medina conducted an unannounced Annual Required Inspection. LPA arrived, introduced self, and allowed entrance by Administrator, Carlo Santos.

All residents were present during today's inspection. Facility toured with Administrator. Facility observed to be clean, odor free, and a comfortable temperature. All resident bedrooms are private, rooms observed to have required furnishings. Bathrooms observed to have grab bars near toilet, and showers observed to have shower chairs, non-skid mats, and grab bars. Water temperature measured at 119 degrees F. Additional linen observed in hallway closet. Living room and dining room have adequate seating for residents. Kitchen toured, knives observed to be locked and secured in drawer near kitchen sink. Facility observed to have a 2-day supply of perishable food and a 7-day supply of non-perishable food available. Pantry is located in hallway. Medications are locked and secured in small cabinet near refrigerator and inaccessible to residents. All medications observed to have original labels and to be administered as prescribed.

Carbon monoxide and smoke detectors present and observed operational during today's inspection. Fire extinguisher present with a service date of 2/20/24. Last fire drill was conducted 1/11/24 according to facility records.

Outside of facility toured. Perimeter is secured with self-latching gate. There are two sheds in the backyard and observed to be locked and inaccessible to residents.

Staff and resident files reviewed. No deficiencies observed during inspection.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 341-3247
LICENSING EVALUATOR NAME: Melinda MedinaTELEPHONE: (559) 410-5914
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2024
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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