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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547202796
Report Date: 10/18/2021
Date Signed: 10/18/2021 03:39:43 PM

Substantiated


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
10/08/2021 and conducted by Evaluator Lisa Salazar
COMPLAINT CONTROL NUMBER: 24-AS-20211008161810
FACILITY NAME:LEE'S COUNTRY HOMEFACILITY NUMBER:
547202796
ADMINISTRATOR:LEE, ELIZABETHFACILITY TYPE:
735
ADDRESS:11282 AVENUE 272TELEPHONE:
(559) 308-1294
CITY:VISALIASTATE: CAZIP CODE:
93277
CAPACITY:4CENSUS: 3DATE:
10/18/2021
UNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Elizabeth Lee, Licensee TIME COMPLETED:
01:15 PM
ALLEGATION(S):
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Staff member used an inappropriate form of punishment on resident in care.
INVESTIGATION FINDINGS:
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On 10/18/2021, Licensing Program Analyst (LPA) L. Salazar arrived to the facility to conduct the required 10 day site inspection. LPA interviewed licensee and Reporting Party. LPA reviewed Resident R1's Individual Performance Plan (IPP).

Based on the information received, Licensee and reporting party both stated a form of discipline for Resident R1, is to get on the ground and do push ups. Based on the information received, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

Per California Code of Regulations, Title 22, Division 6, Chapter 8, a deficiency is being cited on the attached 9099-D. An exit interview was conducted with Licensee Elizabeth Smith. A copy of this report and appeal rights were discussed and provided to Licensee. A plan of correction was developed by licensee and reviewed with LPA.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
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-20211008161810
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: LEE'S COUNTRY HOME
FACILITY NUMBER: 547202796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/18/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/25/2021
Section Cited
CCR
80072(a)(3)
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80072 Personal Rights
(a) Except for children’s residential facilities, each client shall have personal rights which include, but are not limited to, the following:(3) To be free from corporal or unusual punishment, infliction of pain, humiliation, intimidation, ridicule, coercion, threat, mental abuse, or other actions of a punitive nature, including but not limited to: interference with the daily living functions, including eating, sleeping, or toileting; or withholding of shelter, clothing, medication or aids to physical functioning.


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Licensee will cease from this form of discipline. Licensee will collaborate a meeting/plan with R1's psychologist, Board Certified Behavioral Analyst and Service Coordinator. New plan outlying new incentives for behavioral management will be sent to CCL by POC date. **POC date was extended from 24 hours to 10/25/21 to collaborate meeting with Dr., specialists, and Service Coordinator. **
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This requirement was not met as evidenced by interview with Reporting Party and Licensee stating Resident R1 is disciplined by having to get on the ground and do push ups.
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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.
SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Lisa Salazar
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2