Green Gables Care Home III

Type of visit: Required - 1 Year

On 9/10/26 Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Melba Stoops . LPA was granted entry. 6 residents were present during inspection. Designee Mario Ramos (D1) was called and arrived shortly after LPA’s arrival. LPA toured facility with D1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -4 degrees F and refrigerator temperature was maintained at 31 degrees F. Samples of medications were checked and observed kept locked in the kitchen cabinet. Residents’ MARS was reviewed. Fire extinguisher was observed with a purchase date of 10/17/25. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature range of 109.5 to 112.3 in 3 bathrooms. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. First-aid kit observed with all of the required items. Fire drill completed on 7/11/26. All residents and a sample of staff files reviewed to have all the required documents. No deficiencies issued during today's inspection. Exit Interview conducted. LPA is requesting the following documents be submitted to the Fresno CCL office by 9/24/26: Current copy of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization (LIC 309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Liability Insurance, Emergency and Disaster Plan (LIC 610E), Personnel Report (LIC500), Register of Facility Clients/Residents for (LIC9020) A copy of this report was provided to Staff, whose signature on this form confirms receipt of this report.the state’s words, verbatim · CDSS document, Sep 10, 2026

Type of visit: Required - 1 Year

On 9/23/25 Licensing Program Analysts (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was greeted by Staff (S1) Melba Stoops . LPA was granted entry. 6 residents were present during inspection. Designee Mario Ramos (D1) was called and arrived shortly after LPA’s arrival. LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -17 degrees F and refrigerator temperature was maintained at 37 degrees F. Samples of medications were checked and observed kept locked in the kitchen cabinet. Residents’ MARS was reviewed. Fire extinguisher was observed with a purchase date of 10/14/24. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured and observed to be operational. Hot water temperature was tested at a temperature range of 107.7 to 114 in 3 bathrooms. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. First-aid kit observed with all of the required items. Fire drill completed on 9/10/25. All residents and a sample of staff files reviewed to have all the required documents. No deficiencies issued during today's inspection. Exit interview was conducted.The following documents requested to be updated and submitted to Fresno CCL by 10/7/25: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Designee, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Sep 23, 2025

Type of visit: Required - 1 Year

On 10/24/24 at 8:30am Licensing Program Analyst (LPA) J. Leffall arrived unannounced to conduct an Annual Inspection. LPA introduced himself, stated the purpose of the visit, and was greeted by Staff (S1) Melba Stoops . LPA was granted entry. 5 residents were present during inspection. Designee Mario Ramos (D1) was called and arrived shortly after LPA’s arrival. LPA toured facility with S1. The facility was observed to be at a comfortable temperature, clean, in good condition, and no passageway obstructions or fire hazards were observed inside. An adequate supply of perishable and non-perishable food was observed. Freezer temperature was maintained at -10 degrees F and refrigerator temperature was maintained at 36 degrees F. Samples of medications were checked and observed kept locked in the kitchen cabinet. Residents’ MARS was reviewed. Fire extinguisher was observed with a purchase date of 10/14/24. Carbon monoxide and smoke detectors were tested and observed to be operational. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms were toured and observed to be operational. Hot water temperature was tested at a temperature of 109 in resident bathroom 1, 112.4 in bathroom 2, and 115.7 degrees F in bathroom 3. Non-skid mat and grab bars observed in bathrooms. Outside of facility toured. Side gate was self-closing and self-latching. Outside was observed with adequate outdoor seatings available for residents. First-aid kit observed with all of the required items. Fire drill completed on 10/10/24. All residents and a sample of staff files reviewed to have all the required documents. Continued on LIC-809C......... No deficiencies were observed or reported. Exit interview was conducted.The following documents requested to be updated and submitted to Fresno CCL by 11/7/24: Lic 308, Lic 500, Lic 610E, Current Liability Insurance and current Administrator’s certificate. A copy of this report was provided to Designee, whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Oct 24, 2024

Allegation investigated: Questionable Death Staff did not report incident to resident's responsible party

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to deliver investigation findings. LPA met with and explained the reason for the visit with facility Designee Mario Ramos. Administrator was unable to come to the facility at the time of the visit. The Department investigated the allegations listed above. Based on interviews with staff and facility Administrator (AD), on 12/11/23 Resident (R1) who had Dementia, walked out of the facility overnight without staff knowing. R1 was found by staff laying on the sidewalk and 911 was called. It is unknown how long R1 was outside alone in the cold weather. Record Review of medical records reveal that R1 was hospitalized and passed away at the hospital on 12/15/23. R1’s Death Certificate was obtained and lists R1’s cause of death as Acute Respiratory Failure due to Hypothermic Shock. See Lic9099C for continuation of this report Substantiated Record review reveals that R1’s daughter had been the primary contact and completed/signed all admission documents. The facility Admission Agreement lists R1’s daughter as the Responsible Party. R1’s daughter was not notified of the incident by the facility. R1’s daughter was not aware that R1 was hospitalized until contacted by the hospital. Based on interviews and record reviews, The preponderance of evidence standard has been met, therefore both of the above allegations are found to be SUBSTANTIATED. Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D. Civil penalties are pending and currently under review. The details of the civil penalties will be outlined in a future report to the facility. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 19, 2024 · control 24-AS-20240112145413

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87464(f)(1)(c) · Plan of correction due date: Mar 20, 2024

87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined… in (c) "Care and supervision" means the facility assumes responsibility for, or provides or promises to provide in the future, ongoing assistance with activities of daily living without which the resident’s physical health, mental health, safety, or welfare would be endangered… Requirement not met as evidenced by: Licensee did not provide basic services such as care and supervision resulting in R1 exiting the facility without staff knowing. R1 passed away in the hospital. This poses an immediate health, safety or personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: AD has agreed to submit a formal written statement which will include the plan and procedural changes that will be implemented to keep this type of incident from happening again. Training and timeframe to be included. This statement will be submitted to CCLD by POC date.

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87466 · Plan of correction due date: Mar 26, 2024

87466 Observation of the Resident The licensee shall ensure that residents are regularly observed... Licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any. Requirement not met as evidenced by: Licensee did not ensure that R1's Responsible Party was notified that R1 was taken via ambulance to the hospital after being found by staff to have exited the home and experiencing a fall outside. This poses a potential health, safety or personal rights violation to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: AD has agreed to provide inservice to all staff on the facility procedure of contacting required parties when a resident is sent out or experiences a significant change. A copy of procedure and a sign in sheet with names and signatures of staff will be submitted to CCLD by POC date

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Deficiencies visit in conjunction with a complaint visit. LPA met with and explained the reason for the visit with facility Designee Mario Ramos. Administrator was unable to come to the facility at the time of the visit. While conducting a record review in conjunction with a complaint investigation, LPA discovered that Staff (S1) was not cleared to work in the facility. S1 was working during a facility visit on 1/16/2024. On 1/16/24 LPA Brown contacted and informed the Administrator that S1 was to be immediately removed from the facility. AD visited the Regional Office that same day and was informed that S1 could not be Associated to the facility based on not-eligible status. A deficiency for Criminal Background Clearance is being cited on the attached 809-D. Civil penalty is assessed on the attached LIC421BG. An exit interview was conducted and Plan of Correction was developed. A copy of these reports and Appeal Rights were discussed and left with Mario Ramos, whose signature on this form confirms receipt of these documents.the state’s words, verbatim · CDSS document, Mar 19, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355(e)(1) · Plan of correction due date: Mar 20, 2024

87355(e) (1) Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Department... This requirement was not met as evidenced by: Licensee did not ensure S1 had a Criminal Record Clearance. S1 was working on 1/16/24 at the facility. This poses an immediate health, safety or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Mar 19, 2024

Plan of correction: AD removed S1 from the facility. S1 cannot return to the facility unless requirements for Criminal Record Clearance is obtained. DEFICIENCY CLEARED

Type of visit: Required - 1 Year

On 11/17/23, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and requested to meet with Administrator. LPA met with caregiver Melba Stoops. Administrator Maria Sheakalee was called unable to attend meeting. Designated Representative (designee) Mario “Danny” Ramos was called and arrived shortly. LPA toured facility with designee. All 4 residents were present upon inspection. The facility was observed to be at a comfortable temperature at 72 degrees F, clean, in good repair, and no passageway obstructions or fire hazards were observed inside. Fire extinguisher was observed with a service date of:10/12/23. Fire drill last completed on 09/01/23. An adequate supply of perishable and non-perishable food was observed. Medications were checked and observed kept locked in kitchen cabinet. MARS was reviewed. Residents' bedrooms were toured and observed to be adequately furnished with bed, dresser, and adequate lighting. All bathrooms are toured. All bathrooms were observed operating and functioning during inspection. Non-skid mat and grabbed bars were observed. Hot water temperature was tested 112.6 degrees F. in master bathroom and range between 111.1 and 112.0 degrees F. in bathroom 1. Outside of facility toured. Side gate was observed self-closing and free of debris. Adequate outdoor seating available for residents. All residents’ file reviewed to have required documents. LPA reviewed three staff files to have all required documents, fingerprinted cleared and associated to the facility. Carbon monoxide and smoke detectors were tested and observed to be operational. No deficiency was cited during inspection. Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 11/28/23. Forms requested: Lic 308, Lic 500, Lic 610E, current Administrator certificate, control of property, and current liability insurance. A copy of this report was provided to designee whose signature on this form confirms receipt of these report.the state’s words, verbatim · CDSS document, Nov 17, 2023