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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201556
Report Date: 10/24/2024
Date Signed: 10/24/2024 10:55:49 AM

Document Has Been Signed on 10/24/2024 10:55 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
FRESNO RO, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN GABLES CARE HOME IIIFACILITY NUMBER:
107201556
ADMINISTRATOR/
DIRECTOR:
SHEAKALEE, LORIKFACILITY TYPE:
740
ADDRESS:1573 ASH AVENUETELEPHONE:
(559) 325-3707
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 5DATE:
10/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator: Mario RamosTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/24/24 at 8:30am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greeted by Staff (S1) Melba Stoops . LPA was granted entry. 5 residents were present during inspection. Designee Mario Ramos (D1) was called and arrived shortly after LPA’s arrival.

LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good condition, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -10 degrees F and refrigerator temperature was maintained at 36 degrees F. Samples of medications were checked and observed kept locked in the kitchen cabinet. Residents’ MARS was reviewed. Fire extinguisher was observed with a purchase date of 10/14/24.

Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms were toured and observed to be operational. Hot water temperature was tested at a temperature of 109 in resident bathroom 1, 112.4 in bathroom 2, and 115.7 degrees F in bathroom 3. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. First-aid kit observed with all of the required items. Fire drill completed on 10/10/24.

All residents and a sample of staff files reviewed to have all the required documents.



Continued on LIC-809C.........
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2024
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
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 HOME III
FACILITY NUMBER: 107201556
VISIT DATE: 10/24/2024
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No deficiencies were observed or reported.

Exit interview was conducted.The following documents requested to be updated and submitted to Fresno CCL by 11/7/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Designee, whose signature on this form confirms receipt of these report.

SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Jacques Leffall
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024
LIC809 (FAS) - (06/04)
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