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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202796
Report Date: 09/30/2021
Date Signed: 09/30/2021 01:24:03 PM

Document Has Been Signed on 09/30/2021 01:24 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: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:
09/30/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:58 AM
MET WITH:Administrator, Elizabeth LeeTIME COMPLETED:
12:45 PM
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On 09/30/2021, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct a follow-up visit from case management-deficiencies on 08/25/21. LPA introduced self, stated the purpose of the visit and met Administrator, Elizabeth Lee. Two residents were present during the inspection. LPA tour facility and observed one bedroom vacant with no resident. Three bedrooms are single occupant.

No deficiencies issued during this inspection.

Exit Interview conducted. Due to COVID-19 precautionary measures, a copy of this report will be provided via email and an electronic read receipt confirms receiving this email. Report signed on-site

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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