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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 547202796
Report Date: 08/25/2021
Date Signed: 08/25/2021 11:04:09 AM

Document Has Been Signed on 08/25/2021 11:04 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
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: 4DATE:
08/25/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Elizabeth Lee, Administrator TIME COMPLETED:
11:15 AM
NARRATIVE
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Licensing Program Analyst (LPAs) Mai Yang and Lady Cabrera conducted Case Management visit regarding an incident report that was received by Community Care Licensing. LPAs met with Administrator Elizabeth Lee and stated the purpose of the visit. LPAs toured the facility.

On 08/14/2021, approximately 10:30 a.m. it was discovered that Client (C1) left the facility on 08/13/2021 at approximately 7p.m. before the house alarm was set. Facility staff last check in with C1 was at approximately 7p.m. Based on the LPAs interview and records review, the Licensee did not meet California Code of Regulations, Title 22, Division 6, Chapter 6, Section 85065(b) Personnel Requirements. Deficiency is being cited on the attached LIC 809-D.

Exit interview was conducted. A copy of this report, LIC809, LIC809-D, LIC421IM and appeal rights were provided. The Licensee’s signature on this form acknowledges receipt of these documents.

SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Lady Cabrera
LICENSING EVALUATOR SIGNATURE: DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/25/2021
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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Document Has Been Signed on 08/25/2021 11:04 AM - It Cannot Be Edited


Created By: Lady Cabrera On 08/25/2021 at 10:38 AM
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: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2021
Section Cited
CCR
85065(b)

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85065 Personnel Requirements (b)The licensee shall employ staff as necessary to ensure provision of care and supervision to meet client needs.

This requirement is not met as evidenced by:

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Licensee stated Client was moved to another room where staff is able to supervise him. Licensee will place an alarm on his window by by 8/25/2021. Licensee shall submit a current LIC500, along with a written plan in regards to maintain sufficient staff to meet client needs.
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Based on observation, records and interview, the Licensee did not meet care and supervision, which poses an Immediate health, safety or personal rights risk to persons in care.
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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.
SUPERVISOR'S NAME:Sergiy Pidgirny
LICENSING EVALUATOR NAME:Lady Cabrera
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2021


LIC809 (FAS) - (06/04)
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