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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 155801279
Report Date: 05/12/2022
Date Signed: 05/13/2022 10:02:06 AM


Document Has Been Signed on 05/13/2022 10:02 AM - 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:GABLES, THEFACILITY NUMBER:
155801279
ADMINISTRATOR:STEPHANIE HAROFACILITY TYPE:
740
ADDRESS:903 SPIRIT LAKE DRIVETELEPHONE:
(661) 213-3927
CITY:BAKERSFIELDSTATE: CAZIP CODE:
93312
CAPACITY:6CENSUS: DATE:
05/12/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Administrator Stephanie Haro &
Executive Director Michelle Macias 		TIME COMPLETED:
06:00 PM
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On 05/12/2022, Licensing Program Analyst (LPA) L. Salazar arrived at the facility unannounced to deliver findings on complaint allegations. During the visit, LPA observed Resident R1 sitting in a wheel chair moaning in pain. LPA was informed that R1 had broken a bone due to a fall in April and is still recovering.

LPA asked to see a copy of LIC624 (Incident Report). Facility stated report was faxed to CCL but was unable to provide a hard copy of the incident report to LPA.

LPA reviewed Hospice Care plan for R1 and Physician's statement (LIC 602). Records revealed R1 is total assist and is chair bound. LPA reviewed facility's license that states,
"AGE RANGE 60 AND OVER. ALL MAY BE NON-AMBULATORY. HOSPICE WAIVER FOR TWO(2) RESIDENTS WITH APPROVED OPTIONAL TOTAL CARE PLAN"

LPA will return at a later date to address deficiencies, if any, to the facility after the "total care plan" is reviewed in facility's plan of operation located at the Regional Office. No deficiencies cited on todays visit.
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) -65-7914
LICENSING EVALUATOR NAME: Lisa SalazarTELEPHONE: (559) 691-0004
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2022
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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