<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208776
Report Date: 10/31/2023
Date Signed: 10/31/2023 12:25:33 PM


Document Has Been Signed on 10/31/2023 12:25 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 FACILITY, THEFACILITY NUMBER:
107208776
ADMINISTRATOR:SHEAKALEE, ROBERTFACILITY TYPE:
740
ADDRESS:143 W POLSON AVETELEPHONE:
(559) 323-3837
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 6DATE:
10/31/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Mario RamosTIME COMPLETED:
12:35 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) M. Flores and B. Miranda arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explain the purpose of the visit. Administrator Assistant Mario Ramos arrived at the facility minutes after to complete this annual visit.

The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPAs 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 115.2 degrees F.

Kitchen toured, supply of food observed, and food stored properly for perishable and nonperishable. 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 extinguishers was purchased on 10/12/23. Last drill completed on 09/01/23. There was outdoor seating for the residents.

During the visit a file review was conducted for residents and 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 11/07/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage, and Plan of Operation, fire drill training.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) -24-0610
LICENSING EVALUATOR NAME: Miriam FloresTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:
DATE: 10/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/31/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2