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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107208776
Report Date: 08/10/2022
Date Signed: 08/10/2022 05:42:17 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
02/15/2022 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20220215144521
FACILITY NAME:GREEN GABLES CARE FACILITY, THEFACILITY NUMBER:
107208776
ADMINISTRATOR:SHEAKALEE, ROBERTFACILITY TYPE:
740
ADDRESS:143 W POLSON AVETELEPHONE:
(559) 323-3837
CITY:CLOVISSTATE: CAZIP CODE:
93612
CAPACITY:6CENSUS: 6DATE:
08/10/2022
UNANNOUNCEDTIME BEGAN:
04:07 PM
MET WITH:Administrator, Robert SheakaleeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not seek resident timely medical attention.
INVESTIGATION FINDINGS:
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On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver findings for complaint. LPA was not COVID pre-screened at time of entry. Administrator was contacted and was unavailable to come to facility. Administrator gave perimission for Care Giver, Josephine Collado to sign report(s). Reason for visit was discussed. LPA completed a health and safety check on residents in care. Residents observed in common areas and in rooms.

During investigation documentation (physicians report, pre-appraisal, medical records, SOC 341, medication list, incident reports, staff schedule and needs and assessment) was reviewed and interviews were conducted with RP, staff and resident(s). Records reviewed indicated that R1 was able do make their own decisions. Incident was self-reported by facility prior to CCL receiving the SOC 341. Interviews conducted indicated that R1 declined Emergency Medical Services. R1 indicated “they were fine” and it “was their own fault and no fault of the facilities”.

CONT...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 24-AS-20220215144521
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME: GREEN GABLES CARE FACILITY, THE
FACILITY NUMBER: 107208776
VISIT DATE: 08/10/2022
NARRATIVE
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Facility took the necessary steps in an effort to prevent these types of incidents from occurring. Facility has night lights in hallways/passageways, awake night staff, recorded and reported SIR to CCL, offered EMS services and increased checkups on resident after incident. This allegation is UNSUBSTANTIATED.

No deficiencies cited at this visit.

Exit interview completed. A copy of this report given.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Mary Garza
LICENSING EVALUATOR SIGNATURE:

DATE: 08/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2