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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208776
Report Date: 10/02/2024
Date Signed: 10/02/2024 12:18:09 PM


Document Has Been Signed on 10/02/2024 12:18 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 FACILITYFACILITY NUMBER:
107208776
ADMINISTRATOR:SHEAKALEE, ROBERTFACILITY TYPE:
740
ADDRESS:143 W POLSON AVETELEPHONE:
(559) 323-3837
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 5DATE:
10/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Lorik SheakaleeTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Daiquiri Boyd arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explained the purpose of the visit. Administrator Lorik Sheakalee arrived at the facility sometime after to complete this annual visit.

The residence was set at 78 degrees F temperature and free of passageway obstructions inside and outside. LPA observed six bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature was measured at 112.5 degrees F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. During the kitchen tour, LPA discussed cleaning out of kitchen cabinets of crumbs. Medication and knives are locked next to the kitchen area. Cleaning supplies were locked in the hallway. Smoke detectors and carbon monoxide were checked and operating. Fire extinguisher was purchased on 10/12/23. Last drill completed on 09/05/24. There was outdoor seating for the residents.

Emergency food supply was observed and Administrator was advised to update the current supply of emergency food and water. Administrator was advised to update the Emergency Disaster Plan and to post it on the wall.

During the visit a file review was conducted for three residents and two staff files. An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 10/09/2024: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage..

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 243-8080
LICENSING EVALUATOR NAME: Daiquiri BoydTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/02/2024
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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