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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202796
Report Date: 03/15/2022
Date Signed: 03/15/2022 12:40:58 PM

Document Has Been Signed on 03/15/2022 12:40 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:
03/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:43 AM
MET WITH:Elizabeth Lee, LicenseeTIME COMPLETED:
12:35 PM
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On 3/15/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced to conduct an Annual Inspection - Infection Control. LPA introduced self, stated the purpose of the visit, and met with Licensee Elizabeth Lee. LPA conducted a facility tour with Licensee. There are currently no clients present during tour.

Upon entry facility staff was observed with facial covering. Visitor log-in/temperature check was observed upon entry. Hand sanitizer was readily available to clients and visitors. Facility has one entrance/exit point. Facility appeared cleaned with no obstruction or fire clearance issues. Social distancing is maintained in the common and dining areas. LPA observed social distancing and cough etiquette postings in facility.

LPA checked clients’ locked medications and observed a 30-day PPE supplies. Food supply was checked and appeared to be an adequate supply. All clients’ room toured and observed to be adequately furnished and lit. LPA observed three bedrooms that are single occupant and one vacant bedroom. All bathrooms observed trash bin with lid. LPA observed hand washing posting by all sinks. Cleaning supplies were stored and locked in storage room by laundry room.LPA observed fire extinguisher served date: 4/22/21. Last fire drill date 2/5/22.

The exterior tour was conducted. Side gate was self-closing. Staff records were reviewed for good health and infection control training. All clients’ records reviewed to have updated emergency contact information.

No deficiencies issued during this inspection.

Exit Interview conducted. The following documents are requested and submitted to Fresno CCL by: 3/21/22. The following updated forms were requested: Lic 308, Lic 400, Lic 402, Lic 500, Lic 610D, and Lic 9020. LPA received copy of Administrator Certificate and updated facility sketch during facility inspection.

Administrator was informed that as COVID-19 precautionary measure, this report will be provided via email. Report signed on-site.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2022
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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