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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107208776
Report Date: 08/10/2022
Date Signed: 08/10/2022 05:45:51 PM

Document Has Been Signed on 08/10/2022 05:45 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
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:31 PM
MET WITH:Administrator, Robert SheakaleeTIME COMPLETED:
05:53 PM
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On 8/10/2022 Licensing Program Analyst (LPA) M. Garza arrived at facility to deliver findings for a complaint. During visit LPA completed a case management visit. LPA was not COVID pre-screened at time of entry. Administrator was contacted and was unavailable to come to facility. Administrator gave permission for Direct Care Staff, 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 visit LPA observed the following: 2 of 2 staff observed without face coverings, refrigerator with opened food unmarked with dates, refrigerator in need of cleaning, morphine medications being drawn by staff for R1. S1 stated that "sometimes they draw the medication and sometimes hospice does".

This poses both an potential health and safety or personal rights risk to residents in care. Deficiencies cited on LIC 809-D. Technical Violations provided on a TV for food services and infection control.

Exit interview completed. A copy of report and appeal rights 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
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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Document Has Been Signed on 08/10/2022 05:45 PM - It Cannot Be Edited


Created By: Mary Garza On 08/10/2022 at 05:17 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 FACILITY, THE
FACILITY NUMBER: 107208776

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/11/2022
Section Cited
CCR
87633(b)(4)(B)

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87633 Hospice Care of Terminally Ill Residents
(b) A current and complete hospice care plan shall be maintained in the facility...(4) A description of the area of licensee’s responsibility for implementing the plan... (B)... who will control and supervise the storage and administration of all controlled drugs ...without hospice personnel being present.
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Licensee will have hospice pre-draw medication. Training will be completed with staff of regulation. A copy of training material land sign in sheet will be provided to CCL by POC date.
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This requirement was not met as evidence by: LPA’s interviews with S1 and S2, staff stated medication is not pre-drawn for R1. Staff stated the staff at the facility draws it. This possesses a potential threat to resident in care.
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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:See Moua
LICENSING EVALUATOR NAME:Mary Garza
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2022


LIC809 (FAS) - (06/04)
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