107201766-2-26-2026-24-AS-DBOD-DRP3AE-20260226170436

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107201766
Report Date: 02/26/2026
Date Signed: 02/26/2026 05:04:43 PM

Document Has Been Signed on 02/26/2026 05:04 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		FACILITY NUMBER:	107201766
ADMINISTRATOR/ DIRECTOR:	SHEAKALEE, LORIK		FACILITY TYPE:	740
ADDRESS:	385 VARTIKIAN AVENUE		TELEPHONE:	(559) 298-7986
CITY:	CLOVIS	STATE: CA	ZIP CODE:	93612
CAPACITY: 6		CENSUS: 6	DATE:	02/26/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:00 PM
MET WITH:	Mario Ramos		TIME VISIT/ INSPECTION COMPLETED:	05:20 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Daiquiri Boyd and Sarah Hurt arrived at the facility unannounced to conduct a required annual visit. LPA was granted entry by caregiver staff and explain the purpose of the visit. Caregiver staff called Administrator Lorik Sheakalee and advised that someone was on their way and would be at the home shortly. Mario Ramos came to the home and stated that he is the assistant to the Administrator and assisted on this inspection (LIC308 on file and current for this staff).
The residence was set at 72 degrees F temperature and free of passageway obstructions inside and outside. LPA observed five bedrooms in the residence. Residents' rooms were toured and inspected. Rooms were found to be clean, and furnishing was in good condition. Hot water temperature measured 115.8 degrees F.

Kitchen toured, supply of food observed for perishable and nonperishable. Medication and knives are locked in the kitchen area. Laundry room is locked, and stores cleaning supplies Smoke and carbon monoxide, were checked and operating. Fire extinguishers was purchased on 10/17/2025. Last fire drill was completed on 02/03/2026. There was outdoor seating for the residents. Outdoor area was clean and free of obstruction.

LPA's observed safety door knob covers on resident bedroom leading to exit to backyard, and inside chain lock on door leading to back patio out of reach of residents. LPA's observed Resident 1's levothyroxin medication not listed on Centrally Stored Medication record. LPA's observed resident 1's Medical assessment documents special diet that is not being provided. LPA's observed Resident 2's bedroom does not have required lamp furnishing. LPA's observed resident 2's bedroom window does not have window screen.

An exit interview was conducted, and a copy of this report was provided to Caregiver staff, Mario Ramos whose signature confirms receipt.

LPA requested the following updated forms faxed to CCLD by 02/17/25: Personnel Report (LIC 500), Proof of current Liability Coverage

NAME OF LICENSING PROGRAM MANAGER: Sergiy Pidgirny
NAME OF LICENSING PROGRAM ANALYST: Daiquiri Boyd
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/26/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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Document Has Been Signed on 02/26/2026 05:04 PM - It Cannot Be Edited

Created By: Daiquiri Boyd On 02/26/2026 at 04:32 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	FACILITY NUMBER: 107201766
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87555(b)(7)

General Food Service Requirements

(7) Modified diets prescribed by a resident's physician as a medical necessity shall be provided. 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 in Resident 1 is not being provided special diet as documented on 02/27/2026, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2026
	Plan of Correction
1 2 3 4	Administrator will provide Resident 1 special soft diet and submit proof to LPA by POC date of 02/27/2026.

Type A

Section Cited

CCR

87468.1(a)(6)

87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights (6) To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This does not prohibit a licensee from establishing house rules, such as locking doors at night to protect residents, or barring windows against intruders, with permission from the Department. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in LPA's observed child safety locks on resident bedroom leading to otudoor area, and chain lock inside back patio door out of resident reach, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/27/2026
	Plan of Correction
1 2 3 4	Administrator will remove locks and baby safety door knob covers and submit proof to LPA by POC date of 02/27/2026.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Sergiy Pidgirny
NAME OF LICENSING PROGRAM MANAGER:

	Daiquiri Boyd
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/26/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2026

LIC809 (FAS) - (06/04)

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