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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206749
Report Date: 10/13/2022
Date Signed: 10/13/2022 10:40:36 AM

Document Has Been Signed on 10/13/2022 10:40 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:CEDARBROOK MEMORY CARE COMMUNITYFACILITY NUMBER:
107206749
ADMINISTRATOR:SARAH DENNISFACILITY TYPE:
740
ADDRESS:1425 E. NEES AVETELEPHONE:
(559) 412-2299
CITY:FRESNOSTATE: CAZIP CODE:
93720
CAPACITY: 68CENSUS: 59DATE:
10/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:19 AM
MET WITH:Director of Resident Services, Samantha KeithTIME COMPLETED:
10:53 AM
NARRATIVE
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On 10/13/2022, Licensing Program Analyst (LPA) Walton arrived unannounced to conduct a Case Management visit. LPA introduced self, stated the purpose of the visit and requested to meet with the Administrator. LPA met with Director of Resident Services, Samantha Keith.

The purpose of this visit is to follow up on an incident report that was submitted to the Fresno CCL office. It was reported that on 10/03/2022, facility staff pulled medications for R1 and R2 and administered all medications to R1.

A deficiency is being cited in accordance to California Code of Regulations, Title 22, Division 6, on the attached 809D. A civil penalty in the amount of $250 is being assessed for repeat violation.

Exit interview conducted and a plan of correction was reviewed and developed with Director of Resident Services. A copy of this report and appeal rights were discussed and provided to Director of Resident Services, Samantha Keith, whose signature on this form confirms receipt of these documents.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Alexandria Walton
LICENSING EVALUATOR SIGNATURE: DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/13/2022
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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Document Has Been Signed on 10/13/2022 10:40 AM - It Cannot Be Edited


Created By: Alexandria Walton On 10/13/2022 at 10:23 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: CEDARBROOK MEMORY CARE COMMUNITY
FACILITY NUMBER: 107206749

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a)(4): The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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Licensee agrees to submit a written statement detailing the steps the facility will take to ensure the requirements for this section are met to the Fresno CCL office by the POC due date.
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Based on record review, the facility did not ensure the requirements for section 87465(a)(4) were met when facility staff administered medications belonging to R2 to R1, which poses an immediate health and safety risk to residents in care.
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Director of Resident Servcices stated that all staff will be trained on medication administration. A copy of training topics and attendance will be submitted to the Fresno CCL office by 11/4/2022

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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:Melinda Hoffmann
LICENSING EVALUATOR NAME:Alexandria Walton
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022


LIC809 (FAS) - (06/04)
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