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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202796
Report Date: 03/01/2024
Date Signed: 09/20/2024 09:53:29 AM

Document Has Been Signed on 09/20/2024 09:53 AM - 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: 2DATE:
03/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Elizabeth Lee, LicenseeTIME COMPLETED:
03:30 PM
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On 3/15/2024, Licensing Program Analyst LPA K. Kaur arrived unannounced at the above facility to conduct an Annual Inspection. LPA introduced self, stated the purpose of the visit, and was granted entry to the facility by staff Laura Haney. Staff contacted Licnesee Elizabeth Lee who arrived a short while later.

LPA conducted tour with Staff. The facility was observed to be at a comfortable temperature, in good repair, with no passageway obstructions or fire hazards. LPA observed a 7-day supply of non-perishable foods and a 2-day supply of perishable foods. Fire extinguisher in the Kitchen was last serviced on 5/2/2023 and was fully charged. All common areas were properly furnished and well-lit throughout. Medications are kept on the counter in a locked box. First Aid and files in facility office. Chemicals and cleaning supplies are locked in hallway closet. Smoke Alarm and Carbon Monoxide detector tested and operational. All client bedrooms toured and observed to be adequately furnished. LPA observed two bedrooms that are single occupant and two vacant bedrooms and an office. LPA observed in both the residents’ bedrooms some debris on the floor and build up on the baseboards.



LPA toured laundry area which appeared clean. Cleaning supplies and chemicals observed locked in Hallway closet next to laundry. The exterior tour was conducted. The backyard was observed to have sufficient seating under covered area. Medication was reviewed. Staff records were reviewed for good health and training, all clients’ records reviewed to have Admission Agreement, Physician’s Report and emergency contact information. Last fire drill completed on 12/5/2023.

Deficiency is being cited on the attached 809D in accordance with California Code of Regulations, Title 22, Division 6.

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SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE: DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/15/2024
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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Document Has Been Signed on 03/15/2024 03:17 PM - It Cannot Be Edited


Created By: Kamaldeep Kaur On 03/15/2024 at 02:57 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: LEE'S COUNTRY HOME
FACILITY NUMBER: 547202796

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) 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 is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 out of 1, LPA observed bedrooms to have some debris on the floor and build up on the baseboards which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/29/2024
Plan of Correction
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Licensee to complete a deep cleaning and submit pictures to CCLD by due date
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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4
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:See Moua
LICENSING EVALUATOR NAME:Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:
DATE: 03/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/15/2024


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
VISIT DATE: 03/01/2024
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LPA is requesting the following documents be submitted to the Fresno CCL office by 3/29/2024: 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, a printed copy was provided including appeal rights.
SUPERVISORS NAME: See Moua
LICENSING EVALUATOR NAME: Kamaldeep Kaur
LICENSING EVALUATOR SIGNATURE:

DATE: 03/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/15/2024
LIC809 (FAS) - (06/04)
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