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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 547202796
Report Date: 07/17/2023
Date Signed: 07/17/2023 01:16:47 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
05/10/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20230510083343
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:
07/17/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elizabeth Lee, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
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8
9
Licensee did not follow physician's medication orders
Facility has expired food and does not have enough perishable, non-perishable, and nutritious food
Facility is uncleaned
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Kaur and LPM S. Moua arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with Licensee. LPA delivered the following findings.

The Department investigated the allegations listed above. Based on interviews conducted and record review, and documentation and photos from Regional Center the facility failed to follow medication distribution, had expired food, and facility that was not clean.

The preponderance of evidence standard has been met; therefore, the above allegation is found to be
SUBSTANTIATED. See citations on the attached LIC9099D. Exit interview was conducted with Licensee, a copy of this report and appeal rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
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 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 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
05/10/2023 and conducted by Evaluator Kamaldeep Kaur
COMPLAINT CONTROL NUMBER: 24-AS-20230510083343

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:
07/17/2023
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Elizabeth Lee, LicenseeTIME COMPLETED:
01:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Licensee inappropriately has resident caring for other residents and completing staff chores
Licensee inappropriately handled resident in care
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) K. Kaur and LPM S. Moua arrived at the facility unannounced for subsequent complaint inspection. LPA discussed the purpose of the visit and the elements of the allegations with Licensee. LPA delivered the following findings.

The Department investigated the allegations listed above. The Department conducted interviews, reviewed
records. Based on, interviews conducted, and records reviewed, there was no sufficient evidence that Licensee inappropriately has residents caring for other residents and completing staff chores and or Licensee inappropriately handled resident in care. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur; therefore, the allegations are
UNSUBSTANTIATED.

Exit interview conducted with Licensee. A copy of this report was signed and given to Licensee, whose signature confirms receipt of this report.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20230510083343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LEE'S COUNTRY HOME
FACILITY NUMBER: 547202796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/18/2023
Section Cited
CCR
80075(b)
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80075(b) Health Related Services Clients shall be assisted as needed with self-administration of prescription and nonprescription medications.

This requirement was not met as evidenced by:
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Medication error was corrected prior to visit. POC is cleared
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Based on records reviewed, the facility failed to administer R1’s medication as prescribed. R1’s medication was prescribed to be taken in the AM and facility administered it in the PM, which poses an immediate health and safety risk to the residents in care
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9
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14
Type B
07/31/2023
Section Cited
CCR
80076(a)(1)
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2
3
4
5
6
7
80076(a)(1) Food Services All food shall be safe and of thLIC9099e quality and in the quantity necessary to meet the needs of the clients.

This requirement was not met as evidenced by:
1
2
3
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5
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7
All expired food was discarded prior to visit. POC is cleared
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Based on observation and records reviewed, expired food was observed at the facility, which poses a potential health and safety risk to the residents in care.
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9
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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: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20230510083343
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SIERRA CASCADE AC/SC, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LEE'S COUNTRY HOME
FACILITY NUMBER: 547202796
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/31/2023
Section Cited
CCR
80087(a)
1
2
3
4
5
6
7
80087(a) Buildings and Grounds The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Facility was cleaned prior to visit. POC is cleared
8
9
10
11
12
13
14
Based on observation and records reviewed, the facility was observed with dusty and uncleaned pantry shelves and refrigerator, which poses a potential health and safety risk to the residents in care.
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9
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7
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4
5
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7
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2
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5
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7
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2
3
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5
6
7
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: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 4