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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202796
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:05:44 PM

Document Has Been Signed on 01/26/2023 12:05 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
SIERRA CASCADE AC/SC, 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:
01/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth Lee, LicenseeTIME COMPLETED:
12:10 PM
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On 1/26/2023, Licensing Program Analyst (LPA) K.Kaur 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.

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. LPA observed social distancing and cough etiquette postings in facility.

LPA checked clients’ locked medications and observed a 30-day PPE supplies in the kitchen. LPA observed a


7-day supply of non-perishable foods and a 2-day supply of perishable foods. 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 with trash bins with lids. LPA observed hand washing posting by sinks. Cleaning supplies were stored and locked in storage room by laundry room. LPA observed fire extinguisher served date: 4/26/22.

The exterior tour was conducted. Facility pool has a gated fence that was observed locked. 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.


LPA is requesting the following documents be submitted to the Fresno CCL office by 2/02/2023: Current copy
of Administrator Certificate, Designation of Facility Responsibility (LIC308), Administrator Organization
(LIC309), Affidavit regarding Client/Resident Cash Resources (LIC 400), Emergency and Disaster Plan
(LIC610D), Personnel Report (LIC500), Register of Facility Clients/Residents for LIC9020.

An exit interview was conducted with Licensee. Report signed on-site by licensee, printed copy
provided.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/26/2023
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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