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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208776
Report Date: 10/07/2026
Date Signed: 10/07/2026 01:28:52 PM

Document Has Been Signed on 10/07/2026 01:28 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/
DIRECTOR:		SHEAKALEE, ROBERTFACILITY TYPE:
740
ADDRESS:143 W POLSON AVETELEPHONE:
(559) 323-3837
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 6DATE:
10/07/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Mario RamosTIME VISIT/
INSPECTION COMPLETED:
01:45 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) Daiquiri Boyd and LPA Anna Porter made an unannounced visit to the facility for the purpose of conducting a Case Management visit.

A report of a fall came into the Fresno Regional Office and LPA Boyd was unable to find a submitted Serious Incident Report (SIR) for the fall. LPA asked the caregivers and Assistant Administrator(AA) for the SIR records and was told there are none. AA was asked if the copy of the SIR was available to view and copy and AA said that Administrator Lorik Sheakalee was driving and that she could fax it to the office. LPA asked if there was proof that they had previously faxed the report and there was no proof of the SIR for a resident fall.

While at the facility LPAs requested to see the resident binders and were told that all they have at the home is the Medication Administration Record. Assistant Administrator Mario Ramos came approximately 35 minutes later with the facility and resident records in a file box. Currently at the home, they have one resident on hospice and one resident receiving home health services. No Plan of Care for the Home Health agency was found.

LPA reviewed the resident files brought by AA and found that resident 1 has an LIC602A dated 3/8/2025. LPA asked AA if an updated LIC602A existed and was told that was the most recent one.

Resident recliners that were in the living area of the facility, were placed so that 3 recliners were in a line along the back wall, facing the TV. LPA asked caregiver why the chairs in the living room area were moved and why the residents were now in a different place. Caregiver stated that one of the residents was trying to rest and the resident next to her was talking and he could tell by the residents face that she wanted to rest, so he moved the chair of the talking resident, placing another resident in the middle of the two. (continued)
Shawna Doucette
Daiquiri Boyd
DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2026
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 6
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)
Page: 2 of 6
Document Has Been Signed on 10/07/2026 01:28 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 10/07/2026 at 12:00 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 FACILITY
FACILITY NUMBER: 107208776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2026
Section Cited
CCR
87211(a)(10(D)

1
2
3
4
5
6
7
(a)Each licensee shall furnish to the licensing agency... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days...(D)Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as
1
2
3
4
5
6
7
Facility will submit the process for recognizing the need for an SIR and the plan to submit the SIR to Licensing within the regulation time frame. Plan is to be submitted to Licensing by FAX (559)243-8080 by 10/14/26
8
9
10
11
12
13
14
evidenced by no SIRs were found to have been reported to Licensing for a fall that occured with R1. No copy of the SIR was found at the facility, in the resident file, or was able to be provided to Licensing upon request; which poses a potential risk to the health, safety, or personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
10/14/2026
Section Cited
CCR87506(a)

1
2
3
4
5
6
7
87506(a) Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement was not met as evidenced by
1
2
3
4
5
6
7
Facility shall keep a copy of the resident's file at the facility for caregivers and Licensing to have readily available for review. Proof of files provided by FAX (559)243-8080 by 10/14/26
8
9
10
11
12
13
14
LPA requested resident filess and were told there is nothing kept at the facility for the residents. Assistant Administrator said he would bring the files to the home and arrived with files approximately 35 minutes later; which poses a potential risk to the health, safety, or personal rights risk to the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 10/07/2026 01:28 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 10/07/2026 at 12:18 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 FACILITY
FACILITY NUMBER: 107208776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/14/2026
Section Cited
CCR
87609(b)(4)(C)

1
2
3
4
5
6
7
(b)Incidental medical care may be provided to residents through a licensed home health agency...(4)The licensee and home health agency agree in writing on the responsibilities of the home health agency...(C)The written agreement shall be signed by the licensee or licensee
1
2
3
4
5
6
7
Facility shall keep a copy of all home health plan of care for each resident that is receiving those services. Plan of care shall be sent to Licensing for R2 by 10/14/26 by FAX (559)243-8080.
8
9
10
11
12
13
14
representative, and representative of the home health agency, and placed in the resident’s file. This requirement was not met as evidenced by the facility does not have a documented plan of care provided by the home health agency, for R2 receiving home health services; which poses a potential risk to the health, safety, or personal rights risk to the residents in care.
8
9
10
11
12
13
14
Type B
10/14/2026
Section Cited
CCR87468.1(a)(3)

1
2
3
4
5
6
7
(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature, such as withholding
1
2
3
4
5
6
7
Facility staff shall submit documentation of their understanding of Personal Rights for the residents in care. Documentation to be submitted to Licensing by 10/14/26 by FAX(559)243-8080
8
9
10
11
12
13
14
residents’ money or interfering with daily living functions such as eating, sleeping, or elimination. This requirement was not met as evidenced by the assigned resident recliners were arranged in a way to restrict the residents talking to each other and to control what the residents were talking about; which poses a potential risk to the health, safety, or personal rights risk to the residents in care.
8
9
10
11
12
13
14
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 4 of 6
Document Has Been Signed on 10/07/2026 01:28 PM - It Cannot Be Edited


Created By: Daiquiri Boyd On 10/07/2026 at 12:33 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 FACILITY
FACILITY NUMBER: 107208776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/21/2026
Section Cited
CCR
87463(a)

1
2
3
4
5
6
7
The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101,
1
2
3
4
5
6
7
Facility shall obtain an updated Medical Assessment for R1 and provide to Licensing FAX (559)243-8080 by 10/21/26.
8
9
10
11
12
13
14
 Definitions, and to keep the appraisal accurate. For the purposes of this section, the updated pre-admission appraisal shall be referred to as the reappraisal. This requirement is not met as evidenced by the Pre-Admission Appraisal has not been updated since 3/8/2025; which which poses a potential risk to the health, safety, or personal rights risk to the residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Shawna Doucette
NAME OF LICENSING PROGRAM MANAGER:
Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2026


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GREEN GABLES CARE FACILITY
FACILITY NUMBER: 107208776
VISIT DATE: 10/07/2026
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
26
27
28
29
30
31
32
Deficiencies were cited on this day for Personal Rights, for Reporting Requirements, for Reappraisals, and use of Home Health Agencies and Record Keeping.

Appeal rights were provided to Assistant Administrator whose signature on these forms confirms receipt.

NAME OF LICENSING PROGRAM MANAGER: Shawna Doucette
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2026
LIC809 (FAS) - (06/04)
Page: 6 of 6