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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 08/30/2023
Date Signed: 08/30/2023 03:13:05 PM

Document Has Been Signed on 08/30/2023 03:13 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 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: 6DATE:
08/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Mario (Daniel) RamosTIME COMPLETED:
03:25 PM
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Licensing Program Analysts (LPA)'s S. Doucette and M, Flores arrived at the facility unannounced to conduct the Required Annual Inspection. LPA's met with staff, Mario Ramos. LPA's disclosed the purpose of the inspection and was granted entry into the facility by caregiver, Annalyn Meanuel.

A tour of the facility was conducted with staff. The residence was set at 75 F temperature and free of passageway obstructions inside and outside.

Kitchen toured, supply of food observed and food stored properly for perishable and nonperishable. Medications were stored in a locked Medication cabinet. Cleaning supplies were in a locked in a cabinet in the laundry room. Smoke detectors and carbon monoxide detectors were checked and operating. Fire extinguishers were charged and had service dates of 09/22/22.

There was outdoor seating for the residents.

Resident and staff records were reviewed. Current first aid and CPR were reviewed..

Due to time constraints, LPAs will return at a later date to finish the inspection tool and issue citations.



LPAs observed the following deficiencies: Resident records were incomplete, LIC602 not current, staff training incomplete, water temperature was measured at 100 F., resident is sleeping on a mattress with no bedframe, facility does not have a plan of operation or infection control in the facility.

Copy of this report was provided to staff, Mario Ramos.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/30/2023
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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