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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 08/31/2023
Date Signed: 08/31/2023 04:32:34 PM

Document Has Been Signed on 08/31/2023 04:32 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:
08/31/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Mario (Daniel) RamosTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analysts (LPAs) M. Flores and S. Doucette arrived at the facility unannounced to continue the completion of the annual inspection. LPAs were granted entry by caregiver, Analyn Ramos and explain the purpose of the visit.

During the visit a file review was conducted for residents and staff files, refer to 809D for deficiencies.

An exit interview was conducted, and a copy of this report was provided to AD1 whose signature confirms receipt.



LPA requested the following updated forms faxed to CCLD by 9/12/23: Designation of Facility Responsibility (LIC308), Administrative Organization (LIC309), Personnel Report (LIC 500), Proof of current Liability Coverage.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Miriam Flores
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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 65
Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87616(b)
Exceptions for Health Conditions
(b) Written requests shall include, but are not limited to, the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observatio and record review, the licensee did not comply with the section cited above, resident is not allowed to have bed on the floor without an exception which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/15/2023
Plan of Correction
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Licensee agrees to submit physician's note, letter of approval from public guardian, and a letter of request for an exception from the licensee by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(b)
Other Provisions
(b) Each employee who received training and passed the examination required in paragraph (5) of subdivision (a), and who continues to assist with the self-administration of medicines, shall also complete eight hours of in-service training on medication-related issues in each succeeding 12-month period.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review the licensee did not comply with the section cited above, by staff not completing an examination at the end of each online training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will ensure that staff completes all requirements for training by POC due date.
Type B
Section Cited
HSC
1569.69(e)(3)
Other Provisions
(e) Each person who provides employee training under this section shall meet the following education and experience requirements: (3) The licensed residential care facility for the elderly shall maintain the following documentation on each person who provides employee training under this section:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews and record review, the licensee did not comply with the section cited above, staff did not have proper documentation of training by their training provider which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will provide staff training/documentation that meets this regulation and submit proof by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(b)(1)
Medical Assessment
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above physician's report does not have an updated diagnosis for resident R3 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee agrees to get an updated LIC602A and submit a copy by POC due date to the department.
Type B
Section Cited
CCR
87468(d)
Personal Rights of Residents
(d) Licensees shall post the personal rights, nondiscrimination notice, and complaint information specified above in English, and, in any other language in which at least five (5) percent of the residents can only read that other language.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above, facility did not post personal rights which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee agrees to post a copy of personal rights and accessible to residents, licensee will submit a proof of a photo by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(a)(7)(G)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: (7) Procedures that address, but are not limited to, all of the following: (G) A process for identifying residents with special needs, such as hospice, and a plan for meeting those needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above, the facility did not have a complete emergency and disaster plan which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee agrees to have a copy of their emergency and disaster plan at the facility and submit a photo as a proof by POC due date.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 5 of 65
Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(a)(4)
Hospice Care for Terminally Ill Residents
(a) The licensee shall be permitted to accept or retain residents who have been diagnosed as terminally ill by his or her physician and surgeon and who may or may not have restrictive and/or prohibited health conditions, to reside in the facility and receive hospice services from a hospice agency in the facility, when all of the following conditions are met: (4) A written hospice care plan which specifies the care, services, and necessary medical intervention related to the terminal illness as necessary to supplement the care and supervision provided by the facility is developed for each terminally ill resident or prospective resident by that resident's hospice agency and agreed to by the licensee and the resident, or prospective resident, or the resident's or prospective resident's Health Care Surrogate Decision Maker, if any, prior to the initiation of hospice services in the facility for that resident, and all hospice care plans are fully implemented by the licensee and by the hospice(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above, resident file did not have a hospice care plan for residents (R2 and R5) which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee agrees to acquire a hospice care plan for their residents and submit proof to the department by the POC due date

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)(A)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. (A) When any medical assessment, appraisal, or observation indicates that the resident's dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not comply with the section cited above, resident R4 did not have an udpated physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Licensee will update physician's report for resident and submit a copy to the department by POC due date.
Type B
Section Cited
CCR
87705(c)(6)
Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (6) Appraisals are conducted on an ongoing basis pursuant to Section 87463, Reappraisals.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review the licensee did not comply with the section cited above, all residents need an updated pre appraisal which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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2
3
4
Licensee will submit copies of updated preappraisal for their residents to the department by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
Page: 7 of 65
Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 02:41 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, the licensee did not comply with the section cited above the licensee does not have a complete plan of operation in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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2
3
4
Licensee will have a plan of operation in the facility and submit a photo as a proof to the department by POC due date.
Type B
Section Cited
CCR
87412(g)
Personnel Records
(g) All personnel records shall be maintained at the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation and record review, the licensee did not comply with the section cited above, personnel records were not available at the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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4
Licensee agrees to have personnel records at the facility by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/31/2023 04:32 PM - It Cannot Be Edited


Created By: Miriam Flores On 08/31/2023 at 04:03 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 HOME IV, INC.THE
FACILITY NUMBER: 107201766

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(4)(A)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (4) There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal.
(A) In addition to requirements specified in Section 87415, Night Supervision, a facility with fewer than 16 residents shall have at least one night staff person awake and on duty if any resident with dementia is determined through a pre-admission appraisal, reappraisal or observation to require awake night supervision.

This requirement was not met as evidenced by:





Deficient Practice Statement
1
2
3
4
Based on interviews, the licensee did not comply with the section cited above, staff are not awake during the night shift which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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2
3
4
The licensee will submit a new staff schedule and a written statement agreeing to the regulations to the department by POC due date.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Miriam Flores
LICENSING EVALUATOR SIGNATURE:
DATE: 08/31/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/31/2023


LIC809 (FAS) - (06/04)
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