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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 02/22/2022
Date Signed: 02/25/2022 10:42:08 PM

Document Has Been Signed on 02/25/2022 10:42 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN GABLES CARE HOME IV, INC.THEFACILITY NUMBER:
107201766
ADMINISTRATOR:SHEAKALEE, LORIKFACILITY TYPE:
740
ADDRESS:385 VARTIKIAN AVENUETELEPHONE:
(559) 298-7986
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY: 6CENSUS: 5DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Assistant Administrator, Mario RamosTIME COMPLETED:
03:00 PM
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On 02/22/2022, Licensing Program Analyst, M. Garza arrived at the facility unannounced to conduct the required Infection Control Inspection. LPA was greeted by Direct Care Staff and Assistant Administrator, Mario Ramos arrived a short time later. LPA was allowed entry into the facility and screened at entry. LPA observed a central entry point with a supply of hand sanitizer and a sign in policy that includes documented routine symptom screening for resident's, staff and visitors. Residents observed in common area and in rooms.

Mitigation plan was received and uploaded. COVID-19 procedures described in the plan include required postings, symptoms screenings (for staff, persons in care and visitors), testing, quarantine/isolation cohorts, infection control plan to include donning and doffing of Personal Protective Equipment. Staffing and sick leave plans are in place for emergency staffing and/or PPE shortages.

LPA toured the facility inside and out. Required postings of signs to include hand washing, sneezing etiquette and physical distancing were not observed throughout the facility. Staff were all observed wearing face coverings. Facility has designated visitation areas. Covered trash bins were observed. LPA observed a 30 day supply of residents medication. Facility does not have a 30 day supply of PPE. Sinks stocked with hand soap. A supply of paper towels for hand washing and paper towels for hand drying were not observed.

Through LPA observation of documentation and interview with Administrator and staff, the required infection control practices are found to be in compliance. No deficiencies cited on todays inspection. Technical Advisories provided.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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