<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206562
Report Date: 03/16/2022
Date Signed: 03/17/2022 10:33:32 AM

Document Has Been Signed on 03/17/2022 10:33 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:GREEN VILLAFACILITY NUMBER:
107206562
ADMINISTRATOR:SANTOS, CARLOSFACILITY TYPE:
740
ADDRESS:1463 W. SIERRATELEPHONE:
(559) 439-5760
CITY:FRESNOSTATE: CAZIP CODE:
93711
CAPACITY: 6CENSUS: 6DATE:
03/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Carlos Santos - AdministratorTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst(LPA) D. Ayers arrived at the facility unannounced to conduct a Required Annual inspection. LPA met with Administrator Carlos Santos. Administrator certificate is current with renewal date 10/30/2023 .

LPA toured the facility inside and out. All passageways and exits were clear and free from obstruction. The facility was adequately furnished and at a comfortable temperature. All smoke detectors and the carbon monoxide detector were operational. The outdoor space had enough seating for residents in a covered area. The fence had a closing gate with a secure latch. LPA observed a two day supply of perishables and a seven day supply of nonperishable food stuffs. LPA toured all resident bedrooms and bathrooms. Bedrooms were adequately furnished and lit. Resident bathrooms had nonskid mats and secure grab bars in showers, and secure grab bars near toilets. Medications were kept in a locked cabinet in the kitchen, and medications appeared to be administered properly. Chemicals and cleaning supplies were kept in a locked cabinet in the laundry room. Facility had sufficient hygiene items and linen supply for residents.

LPA reviewed Infection Control protocols and best practices and facility Emergency Disaster Plan with Administrator. No deficiencies cited during the inspection. Administrator agreed to provide LPA with updated LIC 500, LIC 9020, and LIC 610E by 3/23/2022. Exit interview conducted. A copy of the report was provided via email.

SUPERVISORS NAME: Andy Xiong
LICENSING EVALUATOR NAME: David Ayers
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 1